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.

Sleep-Related Breathing Disorders: When CPAP Is Not Enough.

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

https://onlinelibrary.wiley.com/doi/pdfdirect/10.1002/alr.23079

International Consensus Statement on Obstructive Sleep Apnea

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

Efficacy of bilevel ventilatory support in the treatment of stable patients with obesity hypoventilation syndrome: systematic review and meta-analysis.

Vinicius André Guerra

Papers

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

Efficacy of bilevel ventilatory support in the treatment of stable patients with obesity hypoventilation syndrome: systematic review and meta-analysis.

Reply - Letter to the editor.