Acute pulmonary embolism. Part 1: epidemiology and diagnosis

The Diagnostic Role of Lung Ultrasound and Contrast-Enhanced Ultrasound in Pulmonary Embolism

The diagnosis of pulmonary embolism (PE) relies essentially on a probabilistic approach that requires careful clinical assessments, targeted laboratory tests, and the use of appropriate imaging tools. Nowadays, the diagnostic gold standard is computed tomographic pulmonary angiography. Lung ultrasound (LUS) can play a role in the diagnosis of PE mainly by allowing the visualization of peripheral lung infarctions. Hypoechoic, pleural-based parenchymal consolidation is the most typical and common finding of pulmonary infarction. More than 85% of infarct lesions are wedge-shaped, extending to the pleural surface and are localized to where the patient complains of pleuritic chest pain. Contrast-enhanced ultrasound can be performed in addition to basic ultrasound examination to ascertain nonvascularization of the consolidation, thus confirming that the lesion is an infarct. The aim of this narrative review is to summarize the latest evidence on the application of LUS to the diagnosis of PE, focusing purely on thoracic/lung signs.

Independent Risk Factors Associated With Venous Thromboembolism After Knee Arthroscopy: A Retrospective Study of 222 Patients

Background

A serious complication after knee arthroscopy is venous thromboembolism (VTE), which includes both deep vein thrombosis (DVT) and pulmonary embolism (PE). However, asymptomatic VTE is frequently undetected.

Purpose

To (1) report the incidence of VTE after knee arthroscopy using ultrasound examination and computed tomography pulmonary angiography (CTPA) and (2) discover the independent risk factors of VTE after knee arthroscopy and determine the corresponding cutoff values of these indicators.

Study Design

Case-control study; Level of evidence, 3.

Methods

Included were 222 patients (115 male) who underwent arthroscopic knee procedures between October 2022 and January 2023. Baseline characteristics, blood test results, and VTE assessments were collected. During the 2-week follow-up, routine lower extremity vascular ultrasound was applied for DVT measurement, with CTPA evaluation for suspected PE. Patients were allocated into VTE and no-VTE groups, and descriptive statistics were used to analyze baseline data. Logistic regression analysis was used to determine the correlation between binary variables and the presence of postoperative VTE. Multivariate logistic regression analysis was further performed to determine the independent risk factors of VTE.

Results

Of the 222 patients, 37 (16.7%) had DVT and 1 (0.5%) had both DVT and PE. Compared to the no-VTE group, the VTE group was significantly older, with more female patients; higher body mass index (BMI) and postoperative D-dimer level; and higher rates of hypertension, hyperlipidemia, varicose veins of the lower extremity, and abnormal postoperative fibrin degradation product level (P≤ .043 for all). Notably, operative time >20 minutes was not significantly associated with postoperative VTE (P = .513). The independent risk factors for VTE included age >32 years (odds ratio [OR], 20.71 [95% CI, 4.40-97.47]; P < .001), BMI >23 kg/m2 (OR, 3.52 [95% CI, 1.11-11.14]; P = .032), hyperlipidemia (OR, 6.81 [95% CI, 1.86-24.88]; P = .004), and postoperative D-dimer level >0.63 mg/L (OR, 34.01 [95% CI, 7.36-157.07]; P < .001).

Conclusion

The incidence of VTE after knee arthroscopy was 16.7% at the 2-week follow-up. Age >32 years, BMI >23 kg/m2, hyperlipidemia, and postoperative D-dimer >0.63 mg/L were independent risk factors of postoperative VTE within 2 weeks after knee arthroscopy. For patients with knee arthroscopy, the cutoff value of postoperative D-dimer for VTE was found to be 0.63 mg/L for timely intervention.

Dust particulate matter increases pulmonary embolism onset: A nationwide time-stratified case-crossover study in China

BACKGROUND

Particulate matter (PM) has been found to elevate the risk of pulmonary embolism (PE) onset. Among the contributors to PM, dust PM stands as the second natural source, and its emissions are escalating due to climate change. Despite this, information on the effect of dust PM on PE onset is scarce. Hence, this study aims to investigate the impacts of dust PM10, dust PM2.5-10, and dust PM2.5 on PE onset.

METHODS

A nationwide time-stratified case-crossover study was conducted between 2015 and 2020, using data from 18,616 PE onset cases across 1,921 hospitals in China. The analysis employed a conditional logistic regression model to quantify the associations between dust PM10, dust PM2.5-10, and dust PM2.5 and PE onset. Furthermore, the study explored the time-distributed lag pattern of the effect of dust PM on PE development. Stratified analyses were performed based on sex, age, region, and season.

RESULTS

Dust PM10, dust PM2.5-10, and dust PM2.5 exhibited significant health effects on PE onset, particularly concerning exposure on the same day. The peak estimates were observed at lag 01 day, with the odds ratio being 1.011 [95 % confidence interval (CI): 1.003, 1.019], 1.014 (95 % CI: 1.003, 1.026), and 1.039 (95 % CI: 1.011, 1.068), for a 10 μg/m3 increase in the concentration of dust PM10, dust PM2.5-10, and dust PM2.5, respectively. In addition, the study identified a higher risk of PE onset associated with dust PM exposure during the warm season than that in cool season, particularly for dust PM2.5.

CONCLUSIONS

The findings from this study suggest that short-term exposure to dust PM, particularly dust PM2.5, may trigger PE onset, posing a significant health threat. Implementing measures to mitigate dust PM emissions and protect patients with PE from dust PM exposure is imperative.

Application of CT pulmonary angiography and echocardiography in acute pulmonary embolism: A cross-sectional study

Background

Pulmonary Embolism (PE) is an acute and potentially fatal condition defined as the blockage of pulmonary arteries by an embolism that can be from various origins.

Objective

The present study aimed to investigate the findings of computed tomography pulmonary angiography (CTPA) and echocardiography in patients with acute PE.

Methods

The present cross-sectional study included some patients with clinical manifestations of PE who underwent CTPA and echocardiography. The radiologic findings, PE severity, and outcome of the patients were recorded. Moreover, echocardiography was performed by an expert cardiologist using a high-resolution device, while CTPA was performed by an expert radiologist using a 16-slice device and a two-step selective test bolus method.

Results

According to our findings, a total number of 147 patients were diagnosed with PE, including 44 (29.93%), 44 (29.93%), and 59 (40.14%) cases of mild, moderate, and severe PE, respectively. Moreover, 25 patients (17%) finally expired due to PE. Regarding the CTPA findings, 31 patients (21.1%) had septum flattening, while 35 (23.8%) had a septum deviation toward the left ventricle. Also, there were significant correlations between mortality and some CTPA findings, including severe PE (p < 0.001), the presence of septal deviation (p = 0.007), and higher diameters of the main pulmonary artery (p < 0.001) and right ventricle (p = 0.008).

Conclusion

CTPA is a valid and accessible modality for diagnosing and evaluating PE in suspected patients. Moreover, several findings in CTPA could predict adverse outcomes, such as death, in patients with PE.

Prognostic Risk Factors of 30-Day Death in Traumatic Lower Limb Fracture Patients with Acute Pulmonary Embolism: A Single-Center Retrospective Study

Background

To explore the prognostic risk factors of 30-day death in patients with traumatic lower limb fracture (TLLF) complicated with acute pulmonary embolism (APE).

Methods

295 consecutive TLLF patients diagnosed as APE according to pulmonary artery CT angiography, hospitalized in our hospital from January 2017 to December 2021, were included in this study. Patients were divided into nonsurvival group and survival group according to 30-day follow-up results. After adjusting age, sex, and all the clinical variables with P values of <0.2 with backward stepwise method (likelihood ratio), multivariate Cox regression analysis was used to analyze risk factors of 30 days all-cause death in TLLF patients with APE. The area under curve (AUC) calculated by receiver operating characteristic curve (ROC) and the incremental model were used to determine the prognostic potential of identified risk factors.

Results

29 patients died during 30-day follow-up. Simplified pulmonary embolism severity index (sPESI) score ≥1 (P < 0.05), Wells score ≥7 (P < 0.01), and pulmonary hypertension (P < 0.01) were associated with higher risk, while anticoagulant therapy (P < 0.01) was associated with lower risk of all-cause death during 30 days follow-up in APE patients. Compared with sPESI score, Wells score plus pulmonary hypertension produced better predictive efficacy. Prognostic value of sPESI score could be enhanced by adding Wells score, pulmonary hypertension, and anticoagulant therapy to the predicting models.

Conclusions

Wells score ≥7 and pulmonary hypertension are independent predictive risk factors of 30-day all-cause death in TLLF patients with APE.

Association between exposure to air pollutants and the risk of hospitalization for pulmonary embolism in Beijing, China: A case-crossover design using a distributed lag nonlinear model

BACKGROUND

Pulmonary embolism (PE) is a life-threatening condition. Few studies have evaluated the relationship between air pollution and PE, and these results have been inconsistent. Therefore, our study aimed to investigate the association between air pollutant exposure and the risk of hospitalization due to PE.

MATERIALS AND METHODS

Daily PE admissions, meteorological data, and ambient pollution data from January 1, 2015, to December 31, 2018, were collected in Beijing. A quasi-Poisson regression model combined with time-stratified case-crossover design and a distributed lag nonlinear model was used to determine the effect of air pollutant exposure on PE admission. To examine the stability of air pollutants' effects, multi-pollutant analyses were performed. Stratified analyses by age and sex were further conducted.

RESULTS

There were 5060 PE admissions during the study period, with an estimated incidence of 6.5 per 100,000. PM_2.5, PM₁₀, SO₂, O₃ and CO exposures were significantly associated with elevated risk of PE hospitalization. The highest cumulative risks were observed at a lag of 0-28 days for PM_2.5 (relative risk [RR] = 1.056, 95% confidence intervals [CI]: 1.015-1.098), PM₁₀ (RR = 1.042, 95%CI: 1.010-1.075), and CO (RR = 1.466, 95%CI: 1.127-1.906), at a lag of 0-27 days for SO₂ (RR = 1.674, 95%CI: 1.200-2.335), and at a lag of 0-4 days for O₃ (RR = 1.019, 95%CI: 1.001-1.038). All associations mentioned above except O₃ remained significant in multi-pollutant models. Stratified analyses showed that women and those aged ≥65 years people were more sensitive to PM₁₀ and CO exposure than men and those aged <65 years. The effect of PM_2.5 exposure was statistically significant in all subgroups.

CONCLUSIONS

Exposure to PM_2.5, PM₁₀, SO₂, and CO showed a positive association with PE hospitalization. High-risk PE groups should take special precautions on days with poor air quality.

Circulating MicroRNAs for Diagnosis of Acute Pulmonary Embolism: Still a Long Way to Go

Venous thromboembolism (VTE) represents the third most frequent cause of acute cardiovascular syndrome. Among VTE, acute pulmonary embolism (APE) is the most life-threatening complication. Due to the low specificity of symptoms clinical diagnosis of APE may be sometimes very difficult. Accordingly, the latest European guidelines only suggest clinical prediction tests for diagnosis of APE, eventually associated with D-dimer, a biomarker burdened by a very low specificity. A growing body of evidence is highlighting the role of miRNAs in hemostasis and thrombosis. Due to their partial inheritance and susceptibility to the environmental factors, miRNAs are increasingly described as active modifiers of the classical Virchow's triad. Clinical evidence on deep venous thrombosis reported specific miRNA signatures associated to thrombosis development, organization, recanalization, and resolution. Conversely, data of miRNA profiling as a predictor/diagnostic marker of APE are still preliminary. Here, we have summarized clinical evidence on the potential role of miRNA in diagnosis of APE. Despite some intriguing insight, miRNA assay is still far from any potential clinical application. Especially, the small sample size of cohorts likely represents the major limitation of published studies, so that extensive analysis of miRNA profiles with a machine learning approach are warranted in the next future. In addition, the cost-benefit ratio of miRNA assay still has a negative impact on their clinical application and routinely test.

An efficient and fast multi-band focused bioimpedance solution with EIT-based reconstruction for pulmonary embolism assessment: a simulation study from massive to segmental blockage

OBJECTIVE

Pulmonary embolism (PE) is an acute condition that blocks the perfusion to the lungs and is a common complication of Covid-19. However, PE is often not diagnosed in time, especially in the pandemic time due to complicated diagnosis protocol. In this study, a non-invasive, fast and efficient bioimpedance method with the EIT-based reconstruction approach is proposed to assess the lung perfusion reliably.

APPROACH

Some proposals are presented to improve the sensitivity and accuracy for the bioimpedance method: (1) a new electrode configuration and focused pattern to help study deep changes caused by PE within each lung field separately, (2) a measurement strategy to compensate the effect of different boundary shapes and varied respiratory conditions on the perfusion signals and (3) an estimator to predict the lung perfusion capacity, from which the severity of PE can be assessed. The proposals were tested on the first-time simulation of PE events at different locations and degrees from segmental blockages to massive blockages. Different object boundary shapes and varied respiratory conditions were included in the simulation to represent for different populations in real measurements.

RESULTS

The correlation between the estimator and the perfusion was very promising (R = 0.91, errors < 6%). The measurement strategy with the proposed configuration and pattern has helped stabilize the estimator to non-perfusion factors such as the boundary shapes and varied respiration conditions (3-5% errors).

SIGNIFICANCE

This promising preliminary result has demonstrated the proposed bioimpedance method's capability and feasibility, and might start a new direction for this application.

Supervised Versus Unsupervised Pulmonary Rehabilitation in Patients with Pulmonary Embolism: A Valuable Alternative in COVID Era

The aim of our study was to assess the effect of 8 weeks of pulmonary rehabilitation (PR) in patients with pulmonary embolism (PE) during unsupervised PR (unSPRgroup) versus supervised PR (SPRgroup) on cardiopulmonary exercise testing (CPET) parameters, sleep quality, quality of life and cardiac biomarkers (NT-pro-BNP). Fourteen patients with PE (unSPRgroup, n = 7, vs. SPRgroup, n = 7) were included in our study (age, 50.7 ± 15.1 years; BMI, 30.0 ± 3.3 kg/m2). We recorded anthropometric characteristics and questionnaires (Quality of life (SF-36) and Pittsburg sleep quality index (PSQI)), we performed blood sampling for NT-pro-BNP measurement and underwent CPET until exhausting before and after the PR program. All patients were subjected to transthoracic echocardiography prior to PR. The SPRgroup differed in mean arterial pressure at rest before and after the PR program (87.6 ± 3.3 vs. 95.0 ± 5.5, respectively, p = 0.010). Patients showed increased levels of leg fatigue (rated after CPET) before and after PR (p = 0.043 for SPRgroup, p = 0.047 for unSPRgroup) while the two groups differed between each other (p = 0.006 for post PR score). Both groups showed increased levels in SF-36 scores (general health; p = 0.032 for SPRgroup, p = 0.010 for unSPRgroup; physical health; p = 0.009 for SPRgroup, p = 0.022 for unSPRgroup) and reduced levels in PSQI (cannot get to sleep within 30-min; p = 0.046 for SPRgroup, p = 0.007 for unSPRgroup; keep up enough enthusiasm to get things done; p = 0.005 for SPRgroup, p = 0.010 for unSPRgroup) following the PR program. The ΝT-pro-BNP was not significantly different before and after PR or between groups. PR may present a safe intervention in patients with PE. The PR results are similar in SPRgroup and unSPRgroup.

Venous thromboembolism

Venous thromboembolism, comprising both deep vein thrombosis and pulmonary embolism, is a chronic illness that affects nearly 10 million people every year worldwide. Strong provoking risk factors for venous thromboembolism include major surgery and active cancer, but most events are unprovoked. Diagnosis requires a sequential work-up that combines assessment of clinical pretest probability for venous thromboembolism using a clinical score (eg, Wells score), D-dimer testing, and imaging. Venous thromboembolism can be considered excluded in patients with both a non-high clinical pretest probability and normal D-dimer concentrations. When required, ultrasonography should be done for a suspected deep vein thrombosis and CT or ventilation-perfusion scintigraphy for a suspected pulmonary embolism. Direct oral anticoagulants (DOACs) are the first-line treatment for almost all patients with venous thromboembolism (including those with cancer). After completing 3-6 months of initial treatment, anticoagulation can be discontinued in patients with venous thromboembolism provoked by a major transient risk factor. Patients whose long-term risk of recurrent venous thromboembolism outweighs the long-term risk of major bleeding, such as those with active cancer or men with unprovoked venous thromboembolism, should receive indefinite anticoagulant treatment. Pharmacological venous thromboembolism prophylaxis is generally warranted in patients undergoing major orthopaedic or cancer surgery. Ongoing research is focused on improving diagnostic strategies for suspected deep vein thrombosis, comparing different DOACs, developing safer anticoagulants, and further individualising approaches for the prevention and management of venous thromboembolism.

Circulating Plasma miRNA and Clinical/Hemodynamic Characteristics Provide Additional Predictive Information About Acute Pulmonary Thromboembolism, Chronic Thromboembolic Pulmonary Hypertension and Idiopathic Pulmonary Hypertension

Idiopathic pulmonary artery hypertension (IPAH), chronic thromboembolic pulmonary hypertension (CTEPH), and acute pulmonary embolism (APTE) are life-threatening cardiopulmonary diseases without specific surgical or medical treatment. Although APTE, CTEPH and IPAH are different pulmonary vascular diseases in terms of clinical presentation, prevalence, pathophysiology and prognosis, the identification of their circulating microRNA (miRNAs) might help in recognizing differences in their outcome evolution and clinical forms. The aim of this study was to describe the APTE, CTEPH, and IPAH-associated miRNAs and to predict their target genes. The target genes of the key differentially expressed miRNAs were analyzed, and functional enrichment analyses were carried out. The miRNAs were detected using RT-PCR. Finally, we incorporated plasma circulating miRNAs in baseline and clinical characteristics of the patients to detect differences between APTE and CTEPH in time of evolution, and differences between CTEPH and IPAH in diseases form. We found five top circulating plasma miRNAs in common with APTE, CTEPH and IPAH assembled in one conglomerate. Among them, miR-let-7i-5p expression was upregulated in APTE and IPAH, while miRNA-320a was upregulated in CTEP and IPAH. The network construction for target genes showed 11 genes regulated by let-7i-5p and 20 genes regulated by miR-320a, all of them regulators of pulmonary arterial adventitial fibroblasts, pulmonary artery endothelial cell, and pulmonary artery smooth muscle cells. AR (androgen receptor), a target gene of hsa-let-7i-5p and has-miR-320a, was enriched in pathways in cancer, whereas PRKCA (Protein Kinase C Alpha), also a target gene of hsa-let-7i-5p and has-miR-320a, was enriched in KEGG pathways, such as pathways in cancer, glioma, and PI3K-Akt signaling pathway. We inferred that CTEPH might be the consequence of abnormal remodeling in APTE, while unbalance between the hyperproliferative and apoptosis-resistant phenotype of pulmonary arterial adventitial fibroblasts, pulmonary artery endothelial cell and pulmonary artery smooth muscle cells in pulmonary artery confer differences in IPAH and CTEPH diseases form. We concluded that the incorporation of plasma circulating let-7i-5p and miRNA-320a in baseline and clinical characteristics of the patients reinforces differences between APTE and CTEPH in outcome evolution, as well as differences between CTEPH and IPAH in diseases form.

Predictive Value of Circulating microRNA-134 Levels for Early Diagnosis of Acute Pulmonary Embolism: Meta-analysis

Acute pulmonary embolism (APE) is a common sudden venous thromboembolism with high rates of morbidity and mortality. Several studies have concluded that microRNA-134 could be a potential biomarker for APE. However, the sensitivity of these studies varies widely. This study aimed to evaluate the diagnostic value of circulating microRNA-134 levels for APE. Four databases were searched to retrieve articles focusing on microRNA-134 detection in APE diagnosis. The Quality Assessment of Diagnostic Accuracy Studies-2 was used to evaluate the quality of the included literature. This meta-analysis included seven studies and 383 subjects. The microRNA-134 levels in APE patients were higher than those in controls (SMD = 2.84, z = 3.69, p < 0.001). The pooled sensitivity, specificity, and diagnostic odds ratio were 0.86 (0.72-0.94), 0.75 (0.66-0.82), and 19 (7-51), respectively. The positive and negative likelihood ratios were 3.4 (2.4-4.8) and 0.18 (0.08-0.40), respectively. The area under the summary receiver operating characteristic curve was 0.81 (0.77-0.84). Circulating microRNA-134 may be a new biomarker for the diagnosis of APE, but more tests and studies are needed to further explore and prove this. Trial registration number: PROSPERO registration #CRD42020184072.

The Predictive Value of microRNA-134 and microRNA-1233 for the Early Diagnosis of Acute Exacerbation of Chronic Obstructive Pulmonary Disease with Acute Pulmonary Embolism

BACKGROUND

The differential diagnosis of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) with acute pulmonary embolism (APE) complications are difficult because of the variability of clinical presentations and the shortage of an unfailing screening biomarkers or instruments.

OBJECTIVE

Aimed to detect and compare the expression of serum microRNAs (miR-1233, miR-134) in AECOPD patients complicated with APE.

PATIENTS/METHODS

Blood samples were collected from 52 AECOPD patients (13 patients with APE complications, 39 patients without APE) and 10 patients with stable COPD. Serum miRNAs expression was detected with real-time quantitative reverse transcription polymerase chain reaction (qRT-PCR). The levels of plasma D-dimers were determined by detection with an enzyme-linked immunosorbent assay (ELISA). The receiver-operator characteristic (ROC) curve was used for evaluating the diagnostic accuracy of the studied miRNAs.

RESULTS

According to the Wells score, 42 of the 52 AECOPD patients were unlikely to have APE (≤4 points), whereas the remaining 10 (>4 points) were likely to have APE. There were 4 cases (4/13 30.8%) in the AECOPD combined with APE group with a Wells score of >4 points. The expression levels of miR-1233 and miR-134 in the serum were considerably upregulated in the AECOPD+APE group compared with the AECOPD group and the stable COPD group (P<0.05). The areas under the curve (AUCs) for miR-134 and miR-1233 were, respectively, 0.931 (95% CI 0.863-0.999) (P<0.05) and 0.884 (95% CI 0.79-0.978) (P<0.05) and were higher compared with the AUC for D-dimer of 0.628 (95% CI 0.447-0.809), the AUC for age-adjusted D-dimer of 0.705 (95% CI 0.525-0.885) and the AUC for Wells score of 0.577 (95% CI 0.389-0.765).

CONCLUSION

Our study indicated that serum miR-1233 and miR-134 have high clinical value in the early diagnosis of AECOPD patients combined with APE, or could be used as potential biomarkers for clinical identification of AECOPD with or without APE complication.

Caring for Critically Ill Adults With Coronavirus Disease 2019 in a PICU: Recommendations by Dual Trained Intensivists

OBJECTIVE

In the midst of the severe acute respiratory syndrome coronavirus 2 pandemic, which causes coronavirus disease 2019, there is a recognized need to expand critical care services and beds beyond the traditional boundaries. There is considerable concern that widespread infection will result in a surge of critically ill patients that will overwhelm our present adult ICU capacity. In this setting, one proposal to add "surge capacity" has been the use of PICU beds and physicians to care for these critically ill adults.

DESIGN

Narrative review/perspective.

SETTING

Not applicable.

PATIENTS

Not applicable.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The virus's high infectivity and prolonged asymptomatic shedding have resulted in an exponential growth in the number of cases in the United States within the past weeks with many (up to 6%) developing acute respiratory distress syndrome mandating critical care services. Coronavirus disease 2019 critical illness appears to be primarily occurring in adults. Although pediatric intensivists are well versed in the care of acute respiratory distress syndrome from viral pneumonia, the care of differing aged adult populations presents some unique challenges. In this statement, a team of adult and pediatric-trained critical care physicians provides guidance on common "adult" issues that may be encountered in the care of these patients and how they can best be managed in a PICU.

CONCLUSIONS

This concise scientific statement includes references to the most recent and relevant guidelines and clinical trials that shape management decisions. The intention is to assist PICUs and intensivists in rapidly preparing for care of adult coronavirus disease 2019 patients should the need arise.

Overexpression of MicroRNA-340-5p Inhibits Pulmonary Arterial Hypertension Induced by APE by Downregulating IL-1β and IL-6

Pulmonary arterial hypertension (PAH) is a fatal cardiovascular disease that could eventually result in right ventricular failure. Recently, the roles of microRNAs (miRNAs) in PAH have been highlighted. The present study aims to investigate the effects of miRNA (miR)-340-5p on PAH induced by acute pulmonary embolism (APE) and the underlying mechanisms. miR-340-5p was lowly expressed, whereas interleukin 1β (IL-1β) and IL-6 were highly expressed in plasma of APE-PAH patients as compared to normal human plasma. Subsequently, IL-1β and IL-6 were confirmed to be two target genes of miR-340-5p using a dual-luciferase reporter gene assay. By conducting overexpression and rescue experiments, overexpression of miR-340-5p was evidenced to inhibit proliferation and migration of pulmonary artery smooth muscle cells (PASMCs) and inflammation via reducing IL-1β and IL-6 levels. Meanwhile, miR-340-5p led to the blocked nuclear factor κB (NF-κB) pathway with reduced NF-κB p65, matrix metalloproteinase 2 (MMP2), and MMP9 expression in PASMCs. Finally, the ameliorative effect of miR-340-5p on pathological lesions was further verified in rat models of APE-PAH. Altogether, overexpressed miR-340-5p inhibited the inflammatory response, proliferation, and migration of PASMCs by downregulating IL-1β and IL-6, thereby suppressing the progression of APE-PAH. miR-340-5p therefore holds promise as an anti-inflammatory therapeutic target.

Increased reporting but decreased mortality associated with adverse events in patients undergoing lung cancer surgery: Competing forces in an era of heightened focus on care quality?

INTRODUCTION

Advances in surgical techniques have improved clinical outcomes and decreased complications. At the same time, heightened attention to care quality has resulted in increased identification of hospital-acquired adverse events. We evaluated these divergent effects on the reported safety of lung cancer resection.

METHODS AND MATERIALS

We analyzed hospital-acquired adverse events in patients undergoing lung cancer resection using the National Hospital Discharge Survey (NHDS) database from 2001-2010. Demographics, diagnoses, and procedures data were abstracted using ICD-9 codes. We used the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSI) to identify hospital-acquired adverse events. Weighted analyses were performed using t-tests and chi-square.

RESULTS

A total of 302,444 hospitalizations for lung cancer resection and were included in the analysis. Incidence of PSI increased over time (28% in 2001-2002 vs 34% in 2009-2010; P<0.001). Those with one or more PSI had increased in-hospital mortality (aOR = 11.1; 95% CI, 4.7-26.1; P<0.001) and prolonged hospitalization (12.5 vs 7.8 days; P<0.001). However, among those with PSI, in-hospital mortality decreased over time, from 17% in 2001-2002 to 2% in 2009-2010.

CONCLUSIONS

In a recent ten-year period, documented rates of adverse events associated with lung cancer resection increased. Despite this increase in safety events, we observed that mortality decreased. Because such metrics may be incorporated into hospital rankings and reimbursement considerations, adverse event coding consistency and content merit further evaluation.

Does Baseline BUN Have an Additive Effect on the Prediction of Mortality in Patients with Acute Pulmonary Embolism?

Background: In patients with heart failure, elevated levels of blood urea nitrogen (BUN) is a prognostic factor. In this study, we investigated the prognostic value of elevated baseline BUN in short-term mortality among patients with acute pulmonary embolism (PE). Methods: Between 2007 and 2014, cardiac biomarkers and BUN levels were measured in patients with acute PE. The primary endpoint was 30-day mortality, evaluated based on the baseline BUN (≥14 ng/L) level in 4 groups of patients according to the European Society of Cardiology's risk stratification (low-risk, intermediate low-risk, intermediate high-risk, and high-risk). Results: Our study recruited 492 patients with a diagnosis of acute PE (mean age=60.58±16.81 y). The overall 1-month mortality rate was 6.9% (34 patients). Elevated BUN levels were reported in 316 (64.2%) patients. A high simplified pulmonary embolism severity index (sPESI) score (OR: 5.23, 95% CI: 1.43-19.11; P=0.012), thrombolytic or thrombectomy therapy (OR: 2.42, 95% CI: 1.01-5.13; P=0.021), and elevated baseline BUN levels (OR: 1.04, 95% CI: 1.01-1.03; P=0.029) were the independent predictors of 30-day mortality. According to our receiver-operating characteristics analysis for 30-day mortality, a baseline BUN level of greater than 14.8 mg/dL was considered elevated. In the intermediate-low-risk patients, mortality occurred only in those with elevated baseline BUN levels (7.2% vs. 0; P=0.008). Conclusion: An elevated baseline BUN level in our patients with PE was an independent predictor of short-term mortality, especially among those in the intermediate-risk group.

Plasma Levels of microRNA-221 (miR-221) are Increased in Patients with Acute Pulmonary Embolism

Background

The aim of this study was to measure and compare the plasma levels of the microRNA (miRNA), miR-221, in patients with acute pulmonary embolism (PE) with healthy individuals and to evaluate the potential role of miR-221 as a diagnostic biomarker for acute PE.

Material/Methods

In blood samples collected from 60 patients with acute PE and 50 healthy volunteers, plasma levels of microRNA were identified using a microRNA microarray, and miR-221 expression was detected using real-time quantitative reverse transcription polymerase chain reaction (qRT-PCR). Brain natriuretic peptide (BNP) and troponin I were measured using an automated immunoassay analyzer. D-dimer levels were measured with an enzyme-linked immunosorbent assay (ELISA).

Results

From the evaluation of 32 differentially expressed plasma miRNAs, miR-221 was significantly upregulated in the plasma of patients with acute PE compared with normal individuals (P<0.05). Correlation analysis showed that plasma miR-221 levels in patients with acute PE were positively correlated with levels of BNP (r=0.842, P<0.05), troponin I (r=0.853; P<0.05), and D-dimer (r=0.838; P<0.05). The receiver operating characteristic (ROC) area under the curve (AUC) for plasma miR-221 was 0.823 (95% CI, 0.757–0.906) (P<0.05), compared with the AUC for D-dimer of 0.768 (95% CI, 0.727–0.853), the AUC for troponin I of 0.713 (95% CI, 0.646–0.868), and the AUC for BNP of 0.648 (95% CI, 0.601–0.723).

Conclusions

Plasma levels of miR-221 were significantly increased in patients with acute PE when compared with healthy individuals.

The role of cardiovascular ultrasound in diagnosis and management of pulmonary embolism

The diagnosis of acute pulmonary embolism (PE) is one of the most important problems in medical emergencies. Commonly accepted criterion for diagnosis of deep venous thrombosis is the lack of vein compressibility assessed by Compression UltraSonography. Echocardiography represents an easily available and reliable imaging technique in the clinical setting of hemodynamic instability and in the direct visualization of thromboembolic masses in the right heart chambers. Moreover, echocardiography is useful for prognostic stratification after acute PE as right ventricular dysfunction is the most important predictor of mortality in this context. This review aims to highlight usefulness, potentialities and perspectives of standard and advanced echocardiography in evaluating patients affected by PE.

Tenecteplase compared with streptokinase and heparin in the treatment of pulmonary embolism: an observational study

Background: Thrombolytics are recommended in high risk patients with massive pulmonary embolism (PE). However, clinical practice seems to be far different and questions related to its utility in less severely affected patients remain the subject of investigation. The objective of this observational study was to compare the efficacy and safety of tenecteplase with streptokinase and heparin. Method: A total of 103 patients (tenecteplase: 62, streptokinase: 17, heparin: 24) diagnosed with PE (massive: 33 [32.04%], submassive: 50 [48.54%], and minor: 20 [19.42%]) were included. Results: Mean age was 50.04 years and major risk factors were immobilization due to hospitalization, history of deep vein thrombosis, and diabetes. Common clinical symptoms of dyspnoea, right ventricular dysfunction, and cough were found in 94.17%, 81.55%, and 77.67% patients, respectively. Between treatment and day 7, death occurred in 4.84%, 5.88%, and 8.33% patients in the tenecteplase, streptokinase, and heparin groups, respectively. The differences among treatment groups were non-significant (p > .05). All treatments have demonstrated significant alleviation of dyspnoea and heart rate (p < .05). Significant (p < .05) increase in oxygen saturation was seen and it was markedly higher in the tenecteplase-treated patients compared with the streptokinase- and heparin-treated patients. By day 7, there was 100% resolution of right bundle branch block only in the tenecteplase group. No intracranial bleeding or fatal bleeding episodes were found in any group. Conclusion: Tenecteplase was found to be effective in patients with PE irrespective of their clinical status and no major adverse events were noted.

Pulmonary embolism: new treatments for an old problem

Nonvitamin K antagonist oral anticoagulants, previously referred to as novel oral anticoagulants, have emerged in recent years as attractive treatment options for acute pulmonary embolism (PE). However, despite the widespread anticipation by physicians and the approval of rivaroxaban, apixaban, dabigatran, and more recently edoxaban, there is still some reluctance to choose these newer agents over conventional treatment with heparin/vitamin K antagonists. Acute PE puts a considerable strain on emergency departments, and medical staff rely on efficient diagnosis and risk assessment to manage the condition appropriately and economically. Rivaroxaban and apixaban offer a convenient and cost-effective single-drug therapeutic approach. The ease of administration and drug management may enable earlier discharge and outpatient treatment in low-risk patients and alleviate the demands put on emergency-care infrastructures. This review discusses the current guidelines and anticoagulation options in the emergency setting for patients with acute PE and explores the reasons for the slow transition from old to new treatment options.

Serum microRNA-1233 is a specific biomarker for diagnosing acute pulmonary embolism

Background

Circulating microRNAs (miRNAs) emerge as novel biomarkers in cardiovascular diseases. Diagnosing acute pulmonary embolism (PE) remains challenging due to a diverse clinical presentation and the lack of specific biomarkers. Here we evaluate serum miRNAs as potential biomarkers in acute PE.

Methods

We enrolled 30 patients with acute, CT (computed tomography)-angiographically confirmed central PE and collected serum samples on the day of emergency room admission (1st day) and from 22 of these patients 9 months thereafter. For comparison, we examined serum samples from patients with acute non ST-segment elevation myocardial infarction (NSTEMI, n = 30) and healthy individuals (n = 12).

Results

We randomly selected 16 out of 30 PE patients and screened sera from the acute (1st day) and chronic stages (9 months) for 754 miRNAs using microarrays and found 37 miRNAs to be differentially regulated. Across all miRNAs, miRNA-1233 displayed the highest fold change (FC) from acute to chronic stage (log₂FC 11.5, p < 0.004). We validated miRNA-1233 by real-time quantitative polymerase chain reaction (RT-qPCR). In acute PE (1st day) we found elevated levels of miRNA-1233 in comparison to NSTEMI (log₂FC 5.7, p < 0.0001) and healthy controls (log₂FC 7.7, p < 0.0001). miRNA-1233 differentiated acute PE from NSTEMI patients and healthy individuals with 90 and 90 % sensitivity, and 100 and 92 % specificity [area under the curve (AUC) 0.95, p < 0.001 and 0.91, p < 0.001], respectively.

Conclusions

This is the first report that identifies a miRNA that allows distinguishing acute PE from acute NSTEMI and healthy individuals with high specificity and sensitivity.

Role of Transthoracic Lung Ultrasonography in the Diagnosis of Pulmonary Embolism: A Systematic Review and Meta-Analysis

Background

Pulmonary embolism (PE) is a potentially life-threatening condition. Although computed tomography pulmonary angiography (CTPA) is the reference standard for diagnosis, its early diagnosis remains a challenge, and the concerns about the radiation exposures further limit the general use of CTPA. The primary aim of this meta-analysis was to evaluate the overall diagnostic accuracy of transthoracic lung ultrasound (TLS) in the diagnosis of PE.

Methods

PubMed, Web of science, OvidSP, ProQuest, EBSCO, Cochrane Library and Clinicaltrial.gov were searched systematically. The quality of included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. The sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR) and hierarchical summary receiver operating characteristic (HSROC) curves were used to examine the TS performance. The Bayes analysis was used to calculate the post-test probability of PE. Publication bias was assessed with Deeks funnel plot.

Results

The results indicated that the sensitivity, specificity, PLR and NLR were 0.85 (95% confidence interval (CI), 0.78 to 0.90), and 0.83 (95% CI, 0.73 to 0.90). And the DOR and HSROC were 28.82 (95% CI, 17.60 to 47.21), 0.91(95% CI, 0.88, 0.93).

Conclusions

The present meta-analysis suggested that transthoracic lung ultrasonography is helpful in diagnosing pulmonary embolism. Although the application of transthoracic lung ultrasound may change some patients’ diagnostic processes, it is inappropriate to generally use transthoracic ultrasonography in diagnosing pulmonary embolism currently.

Pulmonary embolism response teams

OPINION STATEMENT

Pulmonary embolism (PE) is a complex and multidimensional pathophysiology, the diagnosis and management of which spans multiple disciplines. The high morbidity and associated mortality of "massive" and "submassive" acute PE may require prompt, definitive management; however, current consensus guidelines in this domain are not supported by high-level evidence. Randomized clinical trials comparing available pharmacologic and invasive treatment modalities-including anticoagulation, thrombolysis, and embolectomy-have not been conducted and continue to be challenging to conceptualize, design, and execute. Consequently, time-sensitive therapeutic determinations are largely not standardized, and rendered on a case-by-case basis in part depending on institutional practices and expertises. Chronic sequelae of PE, such as chronic thromboembolic pulmonary hypertension and right heart failure, are increasingly identified as conditions necessitating longitudinal specialty care. These and other challenges have created a niche for a multidisciplinary team which can respond rapidly to unstable patient scenarios, appropriately deploy resources, and offer highly specialized acute and chronic management of PE. The Massachusetts General Hospital Pulmonary Embolism Response Team (PERT), modeled after existing rapid response and collaborative care teams, is a novel approach that combines this clinical service with the development of an educational and research framework to advance the care of patients with PE.

Diagnosis and treatment of pulmonary embolism: a multidisciplinary approach

The diagnosis of pulmonary embolism (PE) is frequently considered in patients presenting to the emergency department or when hospitalized. Although early treatment is highly effective, PE is underdiagnosed and, therefore, the disease remains a major health problem. Since symptoms and signs are non specific and the consequences of anticoagulant treatment are considerable, objective tests to either establish or refute the diagnosis have become a standard of care. Diagnostic strategy should be based on clinical evaluation of the probability of PE. The accuracy of diagnostic tests for PE are high when the results are concordant with the clinical assessment. Additional testing is necessary when the test results are inconsistent with clinical probability. The present review article represents the consensus-based recommendations of the Interdisciplinary Association for Research in Lung Disease (AIMAR) multidisciplinary Task Force for diagnosis and treatment of PE. The aim of this review is to provide clinicians a practical diagnostic and therapeutic management approach using evidence from the literature.

A GPS map for pulmonary hypertension: a review of imaging modalities

Pulmonary hypertension (PH) is a lethal disease with a prevalence of 10-20 % in the general population. The current gold standard diagnosis approach is right heart catheterization, directly detecting pulmonary artery pressure. Imaging for PH patients plays an important role in the etiological diagnosis and evaluation of right heart (RV) function, which is a key determinant of morbidity and mortality in PH patients. Currently, echocardiography is the first-line imaging modality for screening PH and evaluating RV function. CMRI is the gold standard method to evaluate RV function. MDCT, radionuclide ventriculography and pulmonary angiography are mostly used in the differential diagnosis of the cause of PH. In this review article, we also mention several newly studied imaging modalities, such as three-dimensional echocardiography, intravascular ultrasound (IVUS) and optical coherence tomography (OCT), which showed promise for early diagnosis of PH.

Correlates of in-hospital deaths among hospitalizations with pulmonary embolism: findings from the 2001-2008 National Hospital Discharge Survey

BACKGROUND

Deep vein thrombosis and pulmonary embolism (PE) are responsible for substantial mortality, morbidity, and impaired health-related quality of life. The aim of this study was to evaluate the correlates of in-hospital deaths among hospitalizations with a diagnosis of PE in the United States.

METHODS

By using data from the 2001-2008 National Hospital Discharge Survey, we assessed the correlates of in-hospital deaths among 14,721 hospitalizations with a diagnosis of PE and among subgroups stratified by age, sex, race, days of hospital stay, type of admission, cancer, pneumonia, and fractures. We produced adjusted rate ratios (aRR) and 95% confidence intervals using log-linear multivariate regression models.

RESULTS

Regardless of the listing position of diagnostic codes, we observed an increased likelihood of in-hospital death in subgroups of hospitalizations with ages 50 years and older (aRR = 1.82-8.48), less than 7 days of hospital stay (aRR = 1.43-1.57), cancer (aRR = 2.10-2.28), pneumonia (aRR = 1.79-2.20), or fractures (aRR = 2.18) (except for first-listed PE), when compared to the reference groups with ages 1-49 years, 7 days or more of hospital stay, without cancer, pneumonia, or fractures while adjusting for covariates. In addition, we observed an increased likelihood of in-hospital death for first-listed PE in hospitalizations of women, when compared to those of men (aRR = 1.45).

CONCLUSIONS

The results of this study provide support for identifying, developing, and implementing effective, evidence-based clinical assessment and management strategies to reduce PE-related morbidity and mortality among hospitalized PE patients who may have concurrent health conditions including cancer, pneumonia, and fractures.

Imaging the right heart: the use of integrated multimodality imaging

During recent years, right ventricular (RV) structure and function have been found to be an important determinant of outcome in different cardiovascular and also pulmonary diseases. Currently, echocardiography and cardiac magnetic resonance (CMR) imaging are the two imaging modalities most commonly used to visualize the RV. Most structural abnormalities of the RV can be reliably described by echocardiography but due its complex geometrical shape, echocardiographic assessment of RV function is more challenging. Newer promising echocardiographic techniques are emerging but lack of validation and limited normal reference data influence their routine clinical application. Cardiac magnetic resonance is generally considered the clinical reference technique due to its unlimited imaging planes, superior image resolution, and three-dimensional volumetric rendering. The accuracy and reliability of CMR measurements make it the ideal tool for serial examinations of RV function. Multidetector computed tomography (MDCT) plays an important role in the diagnosis of pulmonary emboli but can also be used for assessing RV ischaemic disease or as an alternative for CMR if contra-indicated. Radionuclide techniques have become more obsolete in the current era. The different imaging modalities should be considered complimentary and each plays a role for different indications.