Optimal Strategies for the Diagnosis of Acute Pulmonary Embolism: A Health Technology Assessment

To evaluate the feasibility and the efficacy of computed tomography pulmonary angiography (CTPA) in differentiating acute pulmonary embolism (PE) patients with or without right ventricular dysfunction and to evaluate the severity of right ventricular dysfunction in acute PE patients with CPTA. We retrospectively collected and measured the following parameters: right ventricular diameter by short axis in the axial plane (RVDaxial), left ventricular diameter by short axis in the axial plane (LVDaxial), right ventricular diameter by level on the reconstructed four-chamber views (RVD4-CH), left ventricular diameter by level on the reconstructed four-chamber views (LVD4-CH), main pulmonary artery diameter (MPAD), ascending aorta diameter (AOD), coronary sinus diameter (CSD), superior vena cava diameter (SVCD), inferior vena cava (IVC) reflux and interventricular septum deviation by CTPA, and we calculated the RVDaxial/LVDaxial, RVD4-CH/LVD4-CH and MPAD/AOD ratios in acute PE patients. We assessed right ventricular function and pulmonary artery systolic pressure (PASP) by echocardiography (ECHO) and then divided the patients into two groups: group A had right ventricular dysfunction, and group B did not have right ventricular dysfunction. We utilized a logistic regression model to analyse the relationship between right ventricular dysfunction and the measurement parameters obtained from CTPA, and we constructed the ROC curve to confirm the optimal cut-off value of the statistically significant parameter in the logistic regression model. After an initial screening, 113 acute PE patients were enrolled in our study. Among them, 42 patients showed right ventricular dysfunction (37.2 %), and 71 patients showed no right ventricular dysfunction (62.8 %). The difference between the patients with right ventricular dysfunction and patients without right ventricular dysfunction was statistical significant in RVD4-CH/LVD4-CH ratio. Logistic regression model analysis revealed that RVDaxial/LVDaxial ratio and interventricular septum deviation were correlated to right ventricular dysfunction with statistical significance (p = 0.001 and 0.03 respectively). RVDaxial/LVDaxial > 1.02 (95 % CI: 0.818-0.958, p   0.999 (95 % CI 0.722-0.898, p < 0.0001) were determined as the optimal cut-off values following ROC analysis. There was a positive correlation between the MPAD/AOD ratio and PASP (r = 0.408, p = 0.01). Based on the analysis of the parameters obtained by CTPA, the RVDaxial/LVDaxial ratio and interventricular septum deviation could be utilized for predicting right ventricular dysfunction. The MPAD/AOD ratio is a potential adjunct to judge the severity of right ventricular dysfunction in acute PE.

Estimation of right ventricular dysfunction by computed tomography pulmonary angiography: a valuable adjunct for evaluating the severity of acute pulmonary embolism.

Objetivo: descrever o perfil do idoso hospitalizado com doenca cronica nao transmissivel embasados na Teoria de Virginia Henderson. Metodo: Pesquisa quantitativa e descritiva, realizada em junho de 2013. Os participantes sao idosos maiores de 60 anos, admitidos nas clinicas medicas de um Hospital Universitario de Niteroi, RJ. Utilizou-se escalas Katz e Lawton para avaliar capacidades funcionais. Tecnica de coleta questionario semi-estruturado e analise dos dados apresentados em analise estatistica simples. Pesquisa aprovada sob no CAAE-5599.0.000.258-10. Resultados: Total de 43 participantes, 25 (58,14%) do sexo masculino e 18 (41,86%) do sexo feminino, 20 (46,51%) casados, 14 (32,55%) diagnostico principal de doenca cardiovascular, 37 (86,04%) e 24 (55,81%) independentes para as atividades de vida diaria e instrumental, respectivamente. Conclusao: A perspectiva gerontologica implica em considerar a pessoa como sujeita e participante do planejamento das acoes de cuidado, onde a enfermeira identifica as necessidades e especificidades frente ao processo de envelhecimento e hospitalizacao.

Perfil de idosos hospitalizados segundo Viginia Henderson: contribuições para o cuidado em enfermagem

The aim of this cross-sectional study was to describe the profile of smokers hospitalized for surgery, and investigate their motivation to quit. The sample consisted of 100 patients recruited from a university hospital in southern Brazil. Data were collected between February and May 2013, and analyzed using descriptive statistics. The sample was predominantly male (n=58; 58%) and had a mean age of 54.5±13.8 years. Seventy-nine (79%) of the participants were white, 38(38%) were married and 67(67%) had primary education only. Patients started smoking at a mean age of 17±6.6 years, smoked approximately 20(10 to 28.7) cigarettes/day and had been smoking for a mean of 37.4±14.4 years. Ninety-one (91%) patients wanted to stop smoking, 57(57%) were in the preparation phase, 36(36%) had low nicotine dependence and 35(35%) had been encouraged to quit. We concluded that, although hospitalization is a good moment to address smoking cessation, health care professionals do not enact effective and systematic interventions in this regard.

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Profile and motivation for smoking cessation in surgical inpatients

Pulmonary thromboembolism (PTE) is an important cause of mortality/morbidity even today despite advancement in clinical understanding as well as diagnostic facilities. Clinical diagnosis of PTE is often challenging because of nonspecific sign/symptoms. Adherence to clinical decision-making protocols and appropriate use of diagnostic modalities like computed tomography pulmonary angiography can resolve the diagnostic dilemma in most cases and help in the overall management of PTE. This article deals with various concerns as well as controversies surrounding accurate diagnosis of PTE as on date.

Diagnosing pulmonary thromboembolism: Concerns and controversies

Objective : To determine the prevalence of alternative diagnoses based on chest CT angiography (CTA) in patients with suspected pulmonary thromboembolism (PTE) who tested negative for PTE, as well as whether those alternative diagnoses had been considered prior to the CTA. Methods : This was a cross-sectional, retrospective study involving 191 adult patients undergoing CTA for suspected PTE between September of 2009 and May of 2012. Chest X-rays and CTAs were reviewed to determine whether the findings suggested an alternative diagnosis in the cases not diagnosed as PTE. Data on symptoms, risk factors, comorbidities, length of hospital stay, and mortality were collected. Results : On the basis of the CTA findings, PTE was diagnosed in 47 cases (24.6%). Among the 144 patients not diagnosed with PTE via CTA, the findings were abnormal in 120 (83.3%). Such findings were consistent with an alternative diagnosis that explained the symptoms in 75 patients (39.3%). Among those 75 cases, there were only 39 (20.4%) in which the same alterations had not been previously detected on chest X-rays. The most common alternative diagnosis, made solely on the basis of the CTA findings, was pneumonia (identified in 20 cases). Symptoms, risk factors, comorbidities, and the in-hospital mortality rate did not differ significantly between the patients with and without PTE. However, the median hospital stay was significantly longer in the patients with PTE than in those without (18.0 and 9.5 days, respectively; p = 0.001). Conclusions : Our results indicate that chest CTA is useful in cases of suspected PTE, because it can confirm the diagnosis and reveal findings consistent with an alternative diagnosis in a significant number of patients.

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Muriel Bossle Sarmento

Papers

Alternative diagnoses based on CT angiography of the chest in patients with suspected pulmonary thromboembolism.

Tabagismo em pacientes internados em um hospital universitário