Alberto Camaiti

Short-Term Clinical Outcome of Patients With Acute Pulmonary Embolism, Normal Blood Pressure, and Echocardiographic Right Ventricular Dysfunction

BACKGROUND The role of echocardiographic right ventricular (RV) dysfunction in predicting clinical outcome in clinically stable patients with pulmonary embolism (PE) is undefined. In this study, we assessed the prevalence and clinical outcome of normotensive patients with RV dysfunction among a broad spectrum of PE patients. METHODS AND RESULTS This prospective clinical outcome study included cohort of 209 consecutive patients (age, 65+/-15 years) with documented PE. Acute RV dysfunction was diagnosed in the presence of >/=1 of the following: RV dilatation (without hypertrophy), paradox septal systolic motion, and Doppler evidence of pulmonary hypertension. Four groups were identified: 28 patients presenting with shock or cardiac arrest (13%), 19 hypotensive patients without shock (9%), 65 normotensive patients with echocardiographic RV dysfunction (31%), and 97 normotensive patients without RV dysfunction (47%). Among normotensive patients with RV dysfunction, 6 (10%) developed PE-related shock after admission: 3 of these patients died, and 3 were successfully treated with thrombolytic agents. In comparison, none of the 97 normotensive patients without RV dysfunction developed shock or died as a result of PE. CONCLUSIONS A significant proportion (31%) of normotensive patients with acute PE presents with RV dysfunction; these patients with latent hemodynamic impairment have a 10% rate of PE-related shock and 5% in-hospital mortality and may require aggressive therapeutic strategies. Conversely, normotensive patients without echocardiographic RV dysfunction have a benign short-term prognosis. Thus, early detection of echocardiographic RV dysfunction is of major importance in the risk stratification of normotensive patients with acute PE.

Utility of an integrated clinical, echocardiographic, and venous ultrasonographic approach for triage of patients with suspected pulmonary embolism

The potential role of ultrasound techniques in diagnosing acute pulmonary embolism (PE) has been investigated in severe cases with hemodynamic compromise, but is still unclear for the whole clinical spectrum of patients with suspected PE. The aim of this study was to assess the utility of an integrated bedside evaluation for PE based on the combination of a clinical score, 2-dimensional echocardiography, and color venous duplex scanning. A group of 117 consecutive patients with suspected PE was assessed using a clinical likelihood score, echocardiography, and venous duplex scanning in order to obtain a preliminary diagnosis of PE, which was subsequently compared with the final diagnosis obtained by lung perfusion scintigraphy and angiography. A preliminary diagnosis of PE was made in 70 patients; a final diagnosis of PE was made in 63 patients, of which 56 had and 7 did not have a preliminary diagnosis of PE. The preliminary diagnosis therefore showed 89% sensitivity and 74% specificity, with a total accuracy of 82%. In patients with massive PE, sensitivity and negative predictive values of the preliminary diagnosis were 97% and 98%, respectively. Echocardiography was poorly sensitive (51%) but highly specific (87%) for PE. Thus, the integration of clinical likelihood, echocardiography, and venous duplex scanning provides a practical approach to patients with suspected PE, allows the rapid implementation of appropriate management strategies, and may reduce or postpone the need for further instrumental evaluation of more limited access.

Yield of nuclear scan strategy in chest pain unit evaluation of special populations.

BackgroundPatients with chest pain (CP) and nondiagnostic ECG represent heterogeneous population in whom the evaluation of coronary risk factors including metabolic syndrome (MetS) and diabetes mellitus (DM) might improve risk stratification. MethodsWe enrolled 798 consecutive CP patients; 14% presented with MetS and 10% with DM; the remaining 76% presented with other coronary risk profiles (others). All patients underwent maximal exercise tolerance test (ETT) and myocardial perfusion imaging (exercise-MPI). Those with positive testing underwent angiography, whereas the remaining patients were discharged and later followed up. Primary end-point was a composite of coronary stenoses greater than or equal to 50% documented by angiography or coronary events at follow-up. ResultsPatients with MetS or DM had significantly lower survival free from end-point than those patients without (P<0.001). Exercise-MPI showed high negative predictive value in MetS, DM, and others (>96%); however, positive predictive value was 69, 74, and 52%, respectively (P<0.05). ETT alone showed negative predictive value (88%) which was significantly lower than exercise-MPI (98%), (MetS vs. others: P<0.001, and DM vs. others: P=0.05). The area under the receiver-operating characteristic curves obtained from the multivariate model includes clinical data alone, clinical data and ETT results, or clinical data and exercise-MPI results increase progressively. ConclusionA nuclear scan strategy in special populations, including CP patients with MetS or DM, is a valuable tool for risk stratification and adds incremental prognostic value over clinical and ETT values.

Phlegmasia Cerulea Dolens

An 83-year-old man with a recent history of thyroid carcinoma presented with sudden pain and swelling of the left leg with bluish discoloration and livedo reticularis throughout. Two days before admission, swelling of the left lower extremity developed, and the diagnosis of partial left femoral vein thrombosis was confirmed by venous duplex ultrasonography and compression ultrasound. Anticoagulation with low-molecular-weight heparin and oral warfarin was initiated, and the patient was discharged home receiving maintenance anticoagulant therapy and wearing compression stockings. On arrival, the patients arterial blood gas analysis and 12-lead ECG were normal. His blood pressure …

Accuracy of nurse-performed compression ultrasonography in the diagnosis of proximal symptomatic deep vein thrombosis: a prospective cohort study

Compression ultrasonography (CUS) has been recognized as the diagnostic procedure of choice for the investigation of patients with suspected deep vein thrombosis (DVT); the aim of this study was to assess the diagnostic accuracy of nurse‐performed CUS for symptomatic proximal DVT of the lower limb.

Severe Exfoliative Dermatitis Caused by Esomeprazole

Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Sharma: Writing, editing, case management. Aly: Editing. Kavuru: Treating physician and supervising attending. Sponsor’s Role: There were no sponsors for this article.

Giant Abdominal Aortic Aneurysm

An 88-year-old man with a history of smoking, hypertension, and hyperlipidemia was admitted for assessment of a painless abdominal mass. Five years earlier, he had noticed a painless, slowly enlarging abdominal mass; since he was otherwise asymptomatic, he did not seek medical attention. Physical examination revealed a pulsatile, well-defined, nontender abdominal mass (Movie I in the online-only Data Supplement), and a mild bruit was heard on auscultation. Peripheral pulses were palpable in both lower limbs. Ultrasonography of the abdomen showed a giant aortic aneurysm with a large mural thrombus (Figure 1A) and the central sector detected turbulent color flow with duplex image (Movie II in the online-only Data Supplement). Abdominal computed tomography (CT) with intravenous administration of contrast material revealed a …

A ''Google Image'' diagnosis of Madelung's disease

Lesson Given the rare nature of Madelungs disease many clinicians will not have seen a patient with it and will not be able to recognise them: subsequently a diagnosis is unlikely to be made.

General Practitioner–Performed Compression Ultrasonography for Diagnosis of Deep Vein Thrombosis of the Leg: A Multicenter, Prospective Cohort Study

BACKGROUND Patients with suspected deep vein thrombosis (DVT) of the lower limb represent a diagnostic dilemma for general practitioners. Compression ultrasonography (US) is universally recognized as the best test of choice. We assessed the diagnostic accuracy of compression US performed by general practitioners given short training in the management of symptomatic proximal DVT. METHODS From May 2014 to May 2016, we evaluated in a multicenter, prospective cohort study all consecutive outpatients with suspected DVT; bilateral proximal lower limb compression US was performed by general practitioners and by physicians expert in vascular US, each group blinded to the other’s findings. In all examinations with a negative or nondiagnostic result, compression US was repeated by the same operator after 5 to 7 days. Inter-observer agreement and accuracy were calculated. RESULTS We enrolled a total of 1,107 patients. The expert physicians diagnosed DVT in 200 patients, corresponding to an overall prevalence of 18.1% (95% CI, 15.8%–20.3%). The agreement between the trained general practitioners and the experts was excellent (Cohen κ = 0.86; 95% CI, 0.84–0.88). Compression US performed by general practitioners had a sensitivity of 90.0% (95% CI, 88.2%–91.8%) and a specificity of 97.1% (95% CI, 96.2%–98.1%) with a diagnostic accuracy for DVT of 95.8% (95% CI, 94.7%–97.0%). CONCLUSIONS Our results suggest that, even in hands of physicians not expert in vascular US, compression US can be a reliable tool in the diagnosis of DVT. We found that the sensitivity achieved by general practitioners appeared suboptimal, however, so future studies should evaluate the implementation of proper training strategies to maximize skill.

Retrospective Analysis of Giant Abdominal Aortic Aneurysms in a Department of Medicine

industrialized countries in the world. More elderly people are being treated in hospitals. The clinical characteristics of FG in elderly adults (atypical symptoms) differ substantially from in younger individuals (typical symptoms), and severity is strongly associated with older age and agerelated comorbidities. Being female is a risk factor for mortality with FG and is associated with a greater incidence of inflammation of the retroperitoneal space and abdominal cavity. Differences in male and female genital anatomy may be the reason for the rapid spread of infection to the retroperitoneum and fatal outcomes in women. FG is a high-risk disease in women and should be carefully considered, especially in older adults with multiple comorbidities.