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Computed Tomography Pulmonary Angiography in Acute Pulmonary Embolism: The Effect of a Computer-assisted Detection Prototype Used as a Concurrent Reader.

Related Articles

Computed Tomography Pulmonary Angiography in Acute Pulmonary Embolism: The Effect of a Computer-assisted Detection Prototype Used as a Concurrent Reader.

J Thorac Imaging. 2013 Mar 11;

Authors: Wittenberg R, Peters JF, van den Berk IA, Freling NJ, Lely R, de Hoop B, Horsthuis K, Ravesloot CJ, Weber M, Prokop WM, Schaefer-Prokop CM

Abstract
PURPOSE:: To assess the effect of computer-assisted detection (CAD) on diagnostic accuracy, reader confidence, and reading time when used as a concurrent reader for the detection of acute pulmonary embolism in computed tomography pulmonary angiography. MATERIALS AND METHODS:: In this institutional review board-approved retrospective study, 6 observers with varying experience evaluated 158 negative and 38 positive consecutive computed tomography pulmonary angiographies (mean patient age 60 y; 115 women) without and with CAD as a concurrent reader. Readers were asked to determine the presence of pulmonary embolism, assess their diagnostic confidence using a 5-point scale, and document their reading time. Results were compared with an independent standard established by 2 readers, and a third chest radiologist was consulted in case of discordant findings. RESULTS:: Using logistic regression for repeated measurements, we found a significant increase in readers' sensitivity (P<0.001) without loss of specificity (P=0.855) with the effects being reader dependent (P<0.001). Sensitivities varied from 68% to 100% without CAD and from 76% to 100% with CAD. A 2-way analysis of variance showed a small but significant decrease in reading time (P<0.001), with the duration varying between 24 and 208 seconds without CAD and between 17 and 196 seconds with CAD, and a significant increase in readers' confidence scores using CAD as a concurrent reader (P<0.001). CONCLUSIONS:: CAD as a concurrent reader has the potential to increase readers' sensitivity and confidence with a decrease in reading time without loss of specificity. The differences between readers, however, require further evaluation of CAD as a concurrent reader in a larger trial before stronger conclusions can be drawn.

PMID: 23486230 [PubMed - as supplied by publisher]

Incidence of Venous Thromboembolism in Nursing Home Residents.

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Incidence of Venous Thromboembolism in Nursing Home Residents.

J Am Med Dir Assoc. 2013 Mar 13;

Authors: Reardon G, Pandya N, Nutescu EA, Lamori J, Damaraju CV, Schein J, Bookhart B

Abstract
OBJECTIVE: Venous thromboembolism (VTE) is common in the elderly, but its epidemiology in nursing home residents remains unclear. This study estimated rates of VTE recorded on nursing home admission and incidence during residence. DESIGN: Retrospective analysis of AnalytiCare long term care (LTC) database for the period January 2007 to June 2009. SETTING: 181 nursing homes in 19 US states. PARTICIPANTS: Eligible residents had 1 or more admission Minimum Data Set (MDS) 2.0 assessment(s) over the study period. All VTE cases were extracted if MDS indicated deep vein thrombosis or pulmonary embolism. The number of admissions and days at risk were estimated from a random sample (n = 1350) of all residents. MEASUREMENTS: The earliest admission was identified as the admission index date. VTE cases were classified as either "On Admission" (VTE coded on admission index date) or "During Residence" (coded afterward). Residents were followed from admission index date until censoring. RESULTS: A total of 2144 VTE admission cases (3.7% of all admissions) were identified. A further 757 cases of VTE occurring during residence were identified, yielding an incidence of 3.68 cases of VTE per 100 person-years of postadmission residence. VTE admission rates were highest for residents younger than 50 years (4.8%, confidence interval [CI]: 3.9%-5.9%) and 50 to 64 years (5.1%, CI: 4.6%-5.7%) but similar for those aged 65 to 74 (3.6%, CI: 3.3%-4.0%), 75 to 84 (3.6%, CI: 3.3%-3.9%), and 85 years or older (3.1%, CI: 2.9%-3.4%). The incidence of VTE during residence was similar among these age strata. CONCLUSION: Approximately 1 in 25 nursing home admissions had a VTE diagnosis. VTE incidence during residence was higher than reported in earlier nursing home studies. These incidence rates merit further investigation because diagnostic improvements may be driving greater recognition of VTE in LTC.

PMID: 23499170 [PubMed - as supplied by publisher]

Low-molecular-weight or Unfractionated Heparin in Venous Thromboembolism: The Influence of Renal Function.

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Low-molecular-weight or Unfractionated Heparin in Venous Thromboembolism: The Influence of Renal Function.

Am J Med. 2013 Mar 14;

Authors: Trujillo-Santos J, Schellong S, Falga C, Zorrilla V, Gallego P, Barrón M, Monreal M, RIETE Investigators

Abstract
BACKGROUND: In patients with acute venous thromboembolism and renal insufficiency, initial therapy with unfractionated heparin may have some advantages over low-molecular-weight heparin. METHODS: We used the Registro Informatizado de la Enfermedad TromboEmbólica (RIETE) Registry data to evaluate the 15-day outcome in 38,531 recruited patients. We used propensity score matching to compare patients treated with unfractionated heparin with those treated with low-molecular-weight heparin in 3 groups stratified by creatinine clearance levels at baseline: >60 mL/min, 30 to 60 mL/min, or <30 mL/min. RESULTS: Patients initially receiving unfractionated heparin therapy (n = 2167) more likely had underlying diseases than those receiving low-molecular-weight heparin (n = 34,665). Propensity score-matched groups of patients with creatinine clearance levels >60 mL/min (n = 1598 matched pairs), 30 to 60 mL/min (n = 277 matched pairs), and <30 mL/min (n = 210 matched pairs) showed an increased 15-day mortality for unfractionated heparin compared with low-molecular-weight heparin (4.5% vs 2.4% [P = .001], 5.4% vs 5.8% [P = not significant], and 15% vs 8.1% [P = .02], respectively), an increased rate of fatal pulmonary embolism (2.8% vs 1.2% [P = .001], 3.2% vs 2.5% [P = not significant], and 5.7% vs 2.4% [P = .02], respectively), and a similar rate of fatal bleeding (0.3% vs 0.3%, 0.7% vs 0.7%, and 0.5% vs 0.0%, respectively). Multivariate analysis confirmed that patients treated with unfractionated heparin were at increased risk for all-cause death (odds ratio, 1.8; 95% confidence interval, 1.3-2.4) and fatal pulmonary embolism (odds ratio, 2.3; 95% confidence interval, 1.5-3.6). CONCLUSIONS: In comparison with low-molecular-weight heparin, initial therapy with unfractionated heparin was associated with a higher mortality and higher rate of fatal pulmonary embolism in patients with creatinine clearance levels >60 mL/min or <30 mL/min, but not in those with levels between 30 and 60 mL/min.

PMID: 23499331 [PubMed - as supplied by publisher]

Bronchiolite oblitérante postinfectieuse

February 2013
Publication year: 2013
Source:Revue des Maladies Respiratoires, Volume 30, Issue 2



La bronchiolite oblitérante (BO) postinfectieuse est caractérisée par des phénomènes inflammatoires et fibrosants des petites voies aériennes succédant à un épisode infectieux pulmonaire et évoluant vers l’oblitération plus ou moins complète. C’est une cause rare de bronchopathie chronique obstructive, probablement sous-estimée, notamment pour les formes peu étendues. Les formes cliniques diffèrent entre l’enfant et l’adulte. Chez l’enfant, l’adénovirus est le principal agent infectieux en cause, notamment les sérotypes 3,7 et 21 qui sont les plus virulents. Le polymorphisme clinique et radiologique est important avec un pronostic fonctionnel qui dépend de l’extension des lésions pulmonaires. Le diagnostic repose sur la confrontation des données anamnestiques, tomodensitométriques et fonctionnelles. Le traitement est symptomatique et les formes les plus sévères évoluant vers l’insuffisance respiratoire chronique. Chez l’adulte, la fréquence des lésions obstructives définitives est mal connue. Une atteinte parenchymateuse est souvent associée, réalisant un tableau de BO avec pneumonie en voie d’organisation. Cette association modifie la présentation clinique et l’aspect radiologique du tableau infectieux initial et pose souvent de difficile problème de prise en charge. Certains auteurs ont rapporté des cas cliniques avec efficacité présumée d’une corticothérapie systémique mais les données sont parcellaires. Post-infectious bronchiolitis obliterans (BO) is characterized by inflammatory and fibrotic lesions of small airways following a pulmonary infection and leading to some degree of airway obstruction. It represents a rare cause of chronic obstructive pulmonary disease, and is probably underestimated, especially when the lesions affect small areas of the lungs. The clinical features differ between children and adults. In children, adenovirus is the most frequently involved infectious agent, especially the more virulent serotypes 3, 7 and 21. The clinical and radiological signs vary widely and the functional outcome depends on the extent of the lung injury. The diagnosis is based on the medical history, the CT-scan and functional data. The treatment is symptomatic. The most severe forms may result in chronic respiratory insufficiency. In adults, the frequency of obstructive injuries of the small airways in the context of lung infection is unclear. Parenchymal lesions are often present, resulting in BO with organizing pneumonia. These lesions alter the clinical presentation and the radiographic features of the initial infectious disease and often prove difficult to diagnose and manage. Several authors have published clinical cases describing presumed efficacy of systemic corticosteroids but the data are scarce.




Asthme léger de l’enfant : données nouvelles et regain d’intérêt

February 2013
Publication year: 2013
Source:Revue des Maladies Respiratoires, Volume 30, Issue 2



L’asthme léger regroupe l’asthme intermittent et l’asthme persistant léger (APL) selon le Global Initiative for Asthma (GINA). Il représente plus de 75 % des asthmes de l’enfant. Ses manifestations ne sont pas dénuées de retentissement sur la qualité de vie. Le risque d’exacerbation est réel, comme celui de l’évolution vers un asthme plus sévère. C’est pourquoi, il est important de le reconnaître, de le traiter rapidement, et de rechercher et prendre en charge les facteurs de risque d’aggravation. Cependant, on observe encore un sous-diagnostic et donc un traitement insuffisant. L’inflammation bronchique et les phénomènes de remodelage sont présents dans l’asthme léger. Le traitement de référence de l’APL est la corticothérapie inhalée quotidienne, à faible dose. Ses bénéfices sont démontrés. À l’heure actuelle, le traitement intermittent par corticoïdes inhalés ne peut pas être recommandé chez l’enfant. According to the Global Initiative for Asthma (GINA) classification, mild asthma includes intermittent and mild persistent asthma. It represents more than 75% of asthmatic children. The symptoms and functional impact are well described. Mild asthma can lead to severe exacerbations. Progression to more severe disease may occur. Consequently, it is important to diagnose mild asthma, to initiate the appropriate treatment early, and to identify the risk factors for aggravation. Nevertheless, mild asthma is under-diagnosed and under-treated. Bronchial inflammation and remodeling are observed in mild asthma. A daily low-dose of inhaled corticosteroids is the reference treatment for mild persistent asthma. Intermittent inhaled corticosteroids cannot be recommended in children with mild persistent asthma.




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