Mary J. Hughes

Silent pulmonary embolism in patients with distal deep venous thrombosis: Systematic review

PURPOSE The purpose of this investigation was to determine the prevalence of silent pulmonary embolism (PE) in patients with deep venous thrombosis (DVT) limited to the calf veins. METHODS This is a systematic review. We attempted to identify all published investigations that reported the prevalence of silent PE in patients with infrapopliteal DVT. Studies were identified by searching PubMed through January 2014. The search was augmented by manually reviewing the references in all original articles and in reviews. RESULTS The prevalence of silent PE in patients with DVT limited to the calf veins was described in 6 investigations. Pooled data showed a prevalence of 24 of 183 (13.1%) (95% CI 8.9-18.8%). CONCLUSION Silent PE in patients with DVT limited to the calf veins is not rare. Imaging at the time of diagnosis of calf vein DVT, typically with a perfusion scan alone, may be useful, but there is an economic cost and exposure to radiation.

Antimicrobial resistance dashboard application for mapping environmental occurrence and resistant pathogens

An antibiotic resistance (AR) Dashboard application is being developed regarding the occurrence of antibiotic resistance genes (ARG) and bacteria (ARB) in environmental and clinical settings. The application gathers and geospatially maps AR studies, reported occurrence and antibiograms, which can be downloaded for offline analysis. With the integration of multiple data sets, the database can be used on a regional or global scale to identify hot spots for ARGs and ARB; track and link spread and transmission, quantify environmental or human factors influencing presence and persistence of ARG harboring organisms; differentiate natural ARGs from those distributed via human or animal activity; cluster and compare ARGs connections in different environments and hosts; and identify genes that can be used as proxies to routinely monitor anthropogenic pollution. To initially populate and develop the AR Dashboard, a qPCR ARG array was tested with 30 surface waters, primary influent from three waste water treatment facilities, ten clinical isolates from a regional hospital and data from previously published studies including river, park soil and swine farm samples. Interested users are invited to download a beta version (available on iOS or Android), submit AR information using the application, and provide feedback on current and prospective functionalities.

Traumatic rupture of right mainstem bronchus in a child

We report a case of a 7-year-old boy who sustained a ruptured right mainstem bronchus in a motor vehicle accident. The clinical presentation, pathophysiology, and diagnosis of tracheobronchial injuries secondary to nonpenetrating thoracic trauma are discussed.

Posterior hip dislocation in a five-year-old boy: A case report, review of the literature, and current recommendations

Traumatic hip dislocation constitutes a true orthopedic emergency, is a relatively rare occurrence in the pediatric population, and may be accompanied by minimal trauma. Long-term morbidity such as avascular necrosis or osteoarthritis of the femoral head may be significant if the diagnosis is not expeditiously confirmed radiographically and prompt reduction employed. A poorer prognosis is conferred by duration of dislocation for longer than 6 h, advanced skeletal maturity of the patient, severe joint injury, or multiple trauma in the affected patient. A case report involving traumatic hip dislocation in a 5-yr-old boy is described followed by a comparative review of the pediatric and adult literature with current recommendations.

Upper extremity deep venous thrombosis : a case report and review of current diagnostic/therapeutic modalities

Upper extremity deep venous thrombosis is a relatively rare clinical entity with potentially grave sequelae. Pathophysiological mechanisms are currently believed to be multifactorial, involving thoracic compressive forces in conjunction with the activation of the coagulation cascades. Diagnostically, venography remains the gold standard, and the combination of phleborheography and Doppler ultrasound approach a 90% specificity and sensitivity. Numerous therapeutic modalities have been described, and long- term venous patency seems to correlate best with local urokinase and concomitant systemic heparin administration followed by oral anticoagulation and decompressive surgery. A case report is described, and a review of the literature follows. CASE REPORT

Implications of direct amplification for measuring antimicrobial resistance using point-of-care devices

Antimicrobial resistance (AMR) is recognized as a global threat to human health. Rapid detection and characterization of AMR is a critical component of most antibiotic stewardship programs. Methods based on amplification of nucleic acids for detection of AMR are generally faster than culture-based approaches but they still require several hours to more than a day due to the need for transporting the sample to a centralized laboratory, processing of sample, and sometimes DNA purification and concentration. Nucleic acids-based point-of-care (POC) devices are capable of rapidly diagnosing antibiotic-resistant infections which may help in making timely and correct treatment decisions. However, for most POC platforms, sample processing for nucleic acids extraction and purification is also generally required prior to amplification. Direct amplification, an emerging possibility for a number of polymerases, has the potential to eliminate these steps without significantly impacting diagnostic performance. This review summarizes direct amplification methods and their implication for rapid measurement of AMR. Future research directions that may further strengthen the possibility of integrating direct amplification methods with POC devices are also summarized.

Home treatment of deep venous thrombosis in the era of new oral anticoagulants.

This is a retrospective cohort study of adults with a primary diagnosis of deep venous thrombosis (DVT) unaccompanied by pulmonary embolism (PE), seen in 4 emergency departments in 2013 and part of 2014. The purpose was to assess the prevalence of home treatment of DVT in the present era of new oral anticoagulants. Among 96 patients with DVT and no PE, 85 (88.5%) were hospitalized and 11 (11.5%) were discharged to home. Most of the patients discharged to home received low-molecular-weight heparin, 9 (81.8%) of 11. None were prescribed new oral anticoagulants. Early discharge in ≤2 days occurred 28 (32.9%) of 85 patients. Most (64.3%) received enoxaparin and/or warfarin at early discharge. Rivaroxaban was prescribed in 7 (25.0%) of those discharged in ≤2 days. We conclude that in some emergency departments, patients with DVT are uncommonly discharged to home even though new oral anticoagulants are available.

Usefulness of Inferior Vena Cava Filters in Unstable Patients With Acute Pulmonary Embolism and Patients Who Underwent Pulmonary Embolectomy

Administrative data were analyzed from the Premier Healthcare Database, 2010 to 2014, to assess whether inferior vena cava (IVC) filters reduce mortality in unstable patients (in shock or on ventilator support) with acute pulmonary embolism and in stable patients who undergo surgical pulmonary embolectomy. Mortality was assumed to be due to pulmonary embolism in patients who had none of the co-morbid conditions listed in the Charlson Comorbidity Index. Data were determined on the basis of International Classification of Disease-9th Clinical Modification (ICD-9-CM) codes. All-cause mortality in unstable patients was lower with IVC filters in-hospital, 288 of 1,972 (23%) versus 1339 of 3002 (45%) (p <0.0001), and at 3 months, all-cause mortality was 316 of 1,272 (25%) versus 1,428 of 3,002 (48%) (p <0.0001). Pulmonary embolism mortality was lower with IVC filters in unstable patients in-hospital, 191 of 926 (21%) versus 913 of 2,138 (43%) (p <0.0001) and at 3 months, 215 of 926 (23%) versus 971 of 2,138 (45%) (p <0.0001). A lower in-hospital and 3-month all-cause mortality and pulmonary embolism mortality was also shown with IVC filters in stable patients who underwent pulmonary embolectomy. These data, in concert with previous retrospective data, suggest that unstable patients with pulmonary embolism and stable patients who undergo pulmonary embolectomy may benefit from an IVC filter. Further investigations would be useful.

National Trends in Home Treatment of Acute Pulmonary Embolism

Background: Management of patients with acute pulmonary embolism has evolved from obligatory hospitalization to home treatment of carefully selected low-risk patients. The purpose of this investigation is to determine national trends in the prevalence of home treatment of pulmonary embolism. Methods: The Nationwide Emergency Department Sample was used to determine the number of patients seen in emergency departments throughout the United States with a primary (first-listed) diagnosis of pulmonary embolism and the proportion hospitalized according to age, from 2007 to 2012. The National (Nationwide) Inpatient Sample was used to determine in-hospital all-cause mortality and length of stay of hospitalized patients. Patients were adults (≥18 years) of both genders and all races from all regions of the United States. Excluded patients were those in shock or on ventilator support. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify patients and comorbid conditions. Results: Home treatment was selected for 54 494 (6.0%) of 915 702 stable patients with acute pulmonary embolism. The proportion of patients treated at home was age-dependent, highest in those aged 30 years or younger, 12.1%, and lowest in those >80 years, 2.9%. Most patients treated at home, 66.8%, and had no comorbid conditions. In-hospital all-cause deaths were 2.6%. Deaths were ≤0.9% in those ≤40 years and 4.8% in those >80 years. Length of stay was 6 days or longer in 37.6% of patients. Conclusion: In view of the lower death rate among younger patients, they might be a group in whom home treatment would be more advantageous than in elderly patients.

Importance of Early Insertion of Inferior Vena Cava Filters in Unstable Patients with Acute Pulmonary Embolism

BACKGROUND Immortal time bias is a possible confounding factor in cohort studies. In this investigation, we assessed mortality with inferior vena cava (IVC) filters in unstable patients with pulmonary embolism using a design to control for immortal time bias. METHODS Data were from the Premier Healthcare Database, 2010-2014. International Classification of Diseases-Ninth Revision-Clinical Modification codes were used. Unstable patients with pulmonary embolism and an admitting diagnosis of pulmonary embolism, as well as a primary diagnosis of pulmonary embolism, were included. A time-dependent analysis was used according to the day of insertion of the IVC filter to control for immortal time bias. RESULTS Among all unstable patients, irrespective of the use of thrombolytic therapy, in-hospital all-cause mortality was 35 of 180 (19.4%) in those who received an IVC filter vs 122 of 299 (40.8%) with no filter (P < .0001). Mortality was lower in patients in whom the IVC filter was inserted on days 1 or 2 (on day 1, 21.4% compared with 40.8%, P = .017, and on day 2, 14.8% compared with 29.2%, P = .023), but it was not lower in those in whom the filter was inserted on subsequent days. CONCLUSIONS Mortality in unstable patients with pulmonary embolism appeared to be reduced with IVC filters only when the filter was inserted on the first or second day of admission. The design used for these analyses controlled for immortal time bias as a cause of the lower mortality with IVC filters.