Paloma Caballero

Prospective comparison of helical CT with angiography in pulmonary embolism: global and selective vascular territory analysis. Interobserver agreement.

Abstract. The objective of this prospective study was to evaluate the sensitivity, specificity, positive and negative predictive values, and interobserver agreement in the diagnosis of pulmonary embolism with helical CT, compared with pulmonary angiography, for both global results and for selective vascular territories. Helical CT and pulmonary angiography were performed on 66 consecutive patients with clinical suspicion of pulmonary embolism. The exams were blindly interpreted by a vascular radiologist and by two independent thoracic radiologists. Results were analyzed for the final diagnosis as well as separately for 20 different arterial territories in each patient. Pulmonary angiography revealed embolism in 25 patients (38%); 48% were main, 28% lobar, 16% segmental, and 8% subsegmental. The sensitivity, specificity, and positive and negative predictive values of helical CT for observer 1 were, respectively, 91, 81.5, 75, and 94%; in 7.5% of the patients the exam was considered indeterminate. For observer 2 the values were, respectively, 88, 86, 81.5, and 91%; in 9% of the patients the exam was considered indeterminate. Main arteries were considered as non-valuable in 0–0.8%, the lobar in 1.5%, the segmental in 7.5–8.5%, and the subsegmental in 55–60%. Interobserver agreement for the final diagnosis was 80% (kappa 0.65). For each vascular territory, this was 98% (kappa 0.91) for main arteries, 92% (kappa 0.78) for lobar arteries, 79% (kappa 0.56) for segmental arteries, and 59% (kappa 0.21) for subsegmental arteries. Helical CT is a reliable method for pulmonary embolism diagnosis, with good interobserver agreement for main, lobar, and segmental territories. Worse results are found for subsegmental arteries, with high incidence of non-valuable branches and poor interobserver agreement.

Detection of subclinical atherosclerosis in familial hypercholesterolemia using non-invasive imaging modalities

OBJECTIVES To investigate the extent of subclinical atherosclerosis in asymptomatic familial hypercholesterolemia (FH) patients using non-invasive images techniques. PATIENTS, METHODS AND RESULTS The atherosclerotic burden of 36 molecularly defined FH patients (18 males, 45.7±10.9 years) without evidence of cardiovascular disease receiving lipid-lowering treatment and 19 (47.8±11.3 years) controls was investigated. Descending thoracic aorta magnetic resonance imaging (MRI) was performed in a 1.5 T equipment with T1 and T2 sequences to characterize atherosclerotic plaques and to measure aortic wall volumen. Carotid intima-media thickness (cIMT) and presence of plaques were measured using B-mode carotid ultrasound. Mean aortic wall volumen, cIMT and atherosclerotic plaques in aorta were significantly higher in FH cases (P<0.001). A significant correlation between aortic wall volume and cIMT was observed (P<0.01). Aortic MRI detected plaques in 94% and carotid ultrasound in 14% of cases. Lipid-rich plaques were observed only in FH cases (33%) and were associated with family history of premature coronary artery disease (P<0.05). CONCLUSIONS Asymptomatic middle-aged FH patients have significantly higher atherosclerotic burden than controls. cIMT has shown a significant correlation with aortic wall volume and MRI allowed the detection of lipid-rich plaques in FH subjects that were associated with family history of premature coronary artery disease.

Rapid D-dimer test combined a clinical model for deep vein thrombosis Validation with ultrasonography and clinical follow-up in 383 patients

An optimal approach to the diagnosis of deep vein thrombosis (DVT) in lower limbs in the emergency department is still unknown. In this prospective cohort study, we aimed to evaluate the accuracy of the widely available plasma D-dimer test (VIDAS) and establish the usefulness of combining D-dimer testing with a clinical model to reduce the need for serial ultra-sonographies and improve the diagnostic strategy of DVT. We performed a cohort study in 383 consecutive outpatients referred to the emergency department of Hospital La Princesa, with clinical suspicion of DVT. The patients were stratified into three pre-test probability categories using an explicit clinical model (Wells score), and underwent a quantitative automated ELISA D-dimer assay (VIDAS D-Dimer bioMérieux). Patients were managed according to the diagnostic strategy based on clinical probability and compression ultrasonography (CU). Patients for whom DVT was considered a high pre-test probability with negative ultrasonographic findings in the initial CU, returned the following week for repeat ultrasonography. All patients with DVT excluded did not receive anticoagulant therapy, and were followed up for three months to monitor the development of venous thromboembolic complications. DVT was confirmed in 102 patients (26.6%): 95 in the initial test, four in the second test, and three who developed venous thromboembolic complications in the three-month follow-up period. The calculated D-dimer cut-off level was 1 micro g/ml. One hundred patients (98%) with DVT had positive D-dimer. D-dimer had a sensitivity of 98% and a negative predictive value of 98.6%. Among the high-probability patients with positive D-dimer tests and initial negative CU, 9.75% had DVT on repeat CU at one week. The study results suggest that the addition of VIDAS D-dimer to this diagnostic algorithm could improve the management of patients with suspected DVT in daily practice. A diagnostic approach of DVT based on D-dimer (cut-off > or =1 microg/ml) as the first diagnostic tool for the exclusion of DVT, and the clinical probability model as the tool that identifies those patients requiring a second ultrasonography is useful and suitable for daily medical practice.

Clinical validity of negative helical computed tomography for clinical suspicion of pulmonary embolism.

Background: Helical computed tomography has been introduced for the diagnosis of pulmonary embolism. Objective: To determine the clinical safety of withholding anticoagulant treatment in patients with suspicion of pulmonary embolism and negative helical computed tomography study. Methods: During a 9-month period, we performed a prospective study including 209 consecutive patients who underwent helical computed tomography for clinical suspicion of pulmonary embolism. In 53 patients (25.5%), helical computed tomography was diagnostic for pulmonary embolism, and in 24 patients (11.5%) it was indeterminate. In 132 patients (63%), the examination was negative for pulmonary embolism and no anticoagulation treatment was given. A clinical 3-month follow-up was carried out. During this period, 29 patients (22%) were excluded because anticoagulation therapy was initiated for other reasons, or because other diagnostic techniques were performed for pulmonary embolism. Four patients were lost in the 3-month period. In the end, 99 patients (75%) were included in the clinical follow-up. Results: Out of the 99 patients, 9 (9%) died during the 9-month follow-up, the cause of death in each case was not due to thromboembolic venous disease. No venous thromboembolic events were detected in the other 90 patients. Negative predictive value of helical computed tomography for pulmonary embolism was 99.09% (95% CI, 95.03–99.97%). Conclusions: In patients with clinical suspicion of pulmonary embolism and initial negative helical computed tomography from whom anticoagulants are withheld, no thromboembolic disease was detected in a 3-month follow-up. We consider helical computed tomography an effective method for ruling out pulmonary embolism as well as a front-line tool for diagnosis.

Mid term results after bone marrow laser revascularization for treating refractory angina

BackgroundTo evaluate the midterm results of patients with angina and diffuse coronary artery disease treated with transmyocardial revascularization in combination with autologous stem cell therapy.MethodsNineteen patients with diffuse coronary artery disease and medically refractory class III/IV angina were evaluated between June 2007 and December 2009 for sole therapy TMR combined with intramyocardial injection of concentrated stem cells. At the time of surgery, autologous bone marrow (120cc) was aspirated from the iliac crest. A cardiac MRI and an isotopic test were performed before and after the procedure. Follow-up was performed by personal interview.ResultsThere were no perioperative adverse events including no arrhythmias. Mean number of laser channels was 20 and the mean total number of intramyocardially injected cells per milliliter were: total mononuclear cells(83.6 × 106), CD34+ cells(0.6 × 106), and CD133+ cells(0.34 × 106). At 12 months mean follow-up average angina class was significantly improved (3.4 ± 0.5 vs 1.4 ± 0.6; p = 0.004). In addition, monthly cardiovascular medication usage was significantly decreased (348 ± 118 vs. 201 ± 92; p = 0.001). At six months follow up there was a reduction in the number of cardiac hospital readmissions (2.9 ± 2.3 vs. 0.5 ± 0.8; p < 0.001). MRI showed no alterations regarding LV volumes and a 3% improvement regarding ejection fraction.ConclusionsThe stem cell isolator efficiently concentrated autologous bone marrow derived stem cells while the TMR/stem cell combination delivery device worked uneventfully. An improvement in clinical status was noticed in the midterm follow-up. Images test showed no morphological alterations in the left ventricle after the procedure.

Isolated Cardiac Involvement of Rosai-Dorfman Disease

Rosai-Dorfman disease is a rare and multisystem disorder of unknown etiology. It commonly presents as cervical lymph node enlargement, but extranodal involvement may be presented in one-third of the cases. Usually, the clinical course of Rosai-Dorfman disease is benign but it can be malignant, both clinically and pathologically. Herein, we present an isolated cardiac case of extranodal Rosai-Dorfman disease without lymphadenopathy that involves the left ventricle in a symptomatic adult patient and a description of cardiac magnetic resonance imaging findings of this disease.

Fibrosis quística en adultos: acuerdos inter e intraobservador para las escalas de puntuación de Brasfield y Chrispin-Norman en la radiografía de tórax y relación con datos clínicos y espirométricos

Objetivo: La mayoria de los sistemas de puntuacion para la radiografia de torax de pacientes con fibrosis quistica (FQ) se desarrollaron en ninos y se utilizan en adultos. Nuestro objetivo ha sido valorar la variabilidad intra e inter-observador para la radiografia de torax en 2 sistemas de puntuacion en adultos con FQ y relacionarlos con algunos parametros clinicos y espirometricos. Pacientes y metodos: Se han comparado las radiografias de torax de 24 pacientes adultos con FQ mediante 2 sistemas de puntuacion (Brasfield y Chrispin-Norman). Dos radiologos clasificaron los estudios, que revaluo 4 meses despues uno de los 2 observadores. Los acuerdos intra e interobservador se calcularon mediante el coeficiente de correlacion de Pearson (r) y el coeficiente de correlacion intraclase. Las puntuaciones de la radiografia de torax se relacionaron con pruebas de funcion respiratoria y otros datos clinicos. Resultados: Los acuerdos intra e interobservador fueron altos (r = 0,9 y coeficiente de correlacion intraclase = 0,85 en los 2 acuerdos para los 2 sistemas). Los 2 sistemas de puntuacion mostraron correlacion con los datos espirometricos: volumen espiratorio forzado en el primer segundo (FEV1; r = 0,64 y 0,55), FEV1% (r = 0,75 y 0,72) y porcentaje sobre el valor teorico estandar de la capacidad vital forzada (r = 0,63 y 0,056). No encontramos relacion de los sistemas de puntuacion con el sexo, la edad ni el indice de masa corporal. Conclusiones: La radiografia de torax en pacientes adultos con FQ, valorada mediante los sistemas de puntuacion de Brasfield y Chrispin-Norman, presenta buenos acuerdos intra e interobservador. Ambos sistemas de puntuacion presentan una buena correlacion con la funcion pulmonar, especialmente con el FEV1.

Utilidad del dímero-D por ELISA rápido en el diagnóstico de la embolia pulmonar en un servicio de urgencias

Objetivo: Determinar la sensibilidad y el valor predictivo negativo del dimero-D, por enzimoinmunoanalisis (ELISA) rapido, en la embolia pulmonar. Pacientes y metodos: Estudio prospectivo de pacientes atendidos consecutivamente por sospecha clinica de embolia en el Servicio de Urgencias del Hospital de La Princesa de Madrid. El diagnostico de tromboembolia se baso en el algoritmo establecido en el hospital, y se determino el dimero-D por ELISA (VIDAS) en cada paciente con sospecha de embolia pulmonar. A los pacientes con resultado negativo para tromboembolia, establecido por una prueba no considerada de referencia, se les realizo seguimiento clinico a los 3 meses. Resultados: De 132 pacientes con sospecha clinica, 28 (21,2%) fueron positivos y 104 (78,7%) negativos para embolia. El dimero-D fue 0,5 µg/ml, en 74 no se produjo tromboembolia y en 27 si. Si se considera como punto de corte 1 µg/ml, hubo 66 pacientes con valores inferiores, de los que 3 presentaron embolia pulmonar. Otros 66 pacientes mostraron un dimero-D = 1 µg/ml; de ellos, 25 tuvieron un diagnostico positivo para embolia y 41 negativo. La sensibilidad y el valor predictivo negativo para 0,5 µg/ml fue de 96,4 (intervalo de confianza [IC] del 95%, 79,8-99,9) y 96,8 (IC del 95%, 81,5-98,8), respectivamente; para 1 µg/ml fue de 89,2 (IC del 95%, 70,6-97,2) y 95,45 (IC del 95%, 86,4-98,8), respectivamente. Conclusiones: Los valores de dimero-D plasmatico, determinados por la tecnica de ELISA rapido (VIDAS), < 0,5 µg/ml permiten excluir con alto valor predictivo negativo una tromboembolia pulmonar en un servicio de urgencias.

Usefulness of Fast ELISA Determination of D-Dimer Levels for Diagnosing Pulmonary Embolism in an Emergency Room

OBJECTIVE To determine the sensitivity and negative predictive value of D-dimer levels measured by fast enzyme-linked immunoabsorbent assay (ELISA) in pulmonary embolism. PATIENTS AND METHODS Prospective study of consecutive patients with suspicion of pulmonary embolism attended in the Emergency Room of the Hospital de La Princesa in Madrid, Spain. Thromboembolism was diagnosed with an algorithm established in the hospital, and D-dimer levels were determined by fast ELISA (VIDAS D-dimer Assay) in each patient suspected of pulmonary embolism. Patients with negative findings from a test not considered a reference method for thromboembolism were followed for 3 months. RESULTS Of 132 patients with clinical suspicion, 28 (21.2%) were positive and 104 (78.7%) were negative for embolism. D-dimer levels were below 0.5 microg/mL in 31 patients, 30 of whom did not have pulmonary thromboembolism whereas 1 did. D-dimer levels were abowe 0..5 microg/mL in 101 patients; thromboembolism did not occur in 74 of these but was reported in the remaining 27. For a value of 1 microg/mL, 66 patients had values below the cut off, 3 of whom presented pulmonary embolism. The remaining 66 patients had D-dimer levels above or equal to 1 microg/mL; 25 of them had a positive diagnosis for embolism and 41 had a negative diagnosis. Sensitivity and negative predictive values were 96.4% (95% confidence interval [CI], 79.8%-99.9%) and 96.8% (95% CI, 81.5%-98.8%), respectively, at a cut off of 0.5 microg/mL; and 89.2% (95% CI, 70.6%-97.2%) and 95.45% (95% CI, 86.4%-98.8%), respectively, at a cut off of 1 microg/mL. CONCLUSIONS In an emergency room, thromboembolism can be excluded if plasma levels of D-dimer measured by fast ELISA are below 0.5 microg/mL because of the high negative predictive value at this cut off.

Trombosis venosa profunda en miembros inferiores en un servicio de urgencias. Utilidad de un modelo clínico de estratificación de riesgo

Fundamento La trombosis venosa profunda (TVP) es un proceso de dificil diagnostico. Se pretendeevaluar la utilidad y efectividad diagnostica de un cuestionario de estratificacion de riesgoclinico y de una estrategia diagnostica aplicadas a pacientes con sospecha de TVP en miembrosinferiores (MMII) en un servicio de urgencias. Pacientes y metodo Estudio prospectivo de 569 pacientes que acudieron al servicio de urgenciascon sospecha de TVP en MMII durante 14 meses. Se les aplico un cuestionario que estratificaen grupos de probabilidad pretest (alta, moderada o baja) segun sintomas-signos, factoresde riesgo y diagnosticos alternativos. Se diagnostico TVP mediante una estrategia que combinael modelo de estratificacion con eco-Doppler inicial y repeticion del eco-Doppler a los pacientesde riesgo medio-alto y primer eco-Doppler negativo, con seguimiento clinico (tres meses). Resultados La probabilidad clinica era baja en 203 pacientes (35,7%), media en 186(32,7%) y alta en 180 (31,6%). Se diagnostico TVP a 153 pacientes (26,9%), al 96% con elprimer eco-Doppler, 3,5% con el segundo y 0,7% por seguimiento clinico. Presentaban bajoriesgo 22 pacientes (11%; intervalo de confianza [IC] del 95%, 7-16%); en 43 (23%; IC del95%, 17-30%) el riesgo era medio y en 88 (49%; IC del 95%, 41-56%), alto. La diferencia deprevalencia de TVP entre categorias fue significativa (p Conclusiones El modelo de estratificacion clinico utilizado es valido, util y sencillo, aunque insuficientecomo unica herramienta para tomar decisiones. La estrategia diagnostica utilizada esefectiva, pero poco eficiente.