Journal of Thrombosis and Haemostasis

Treatment


1. J Thromb Haemost. 2015 Nov 11. doi: 10.1111/jth.13188. [Epub ahead of print]

Multidetector computed tomographic pulmonary angiography in patients with a high
clinical probability of pulmonary embolism.

Moores L(1), Kline J(2), Portillo AK(3), Resano S(4), Vicente A(4), Arrieta P(5),
Corres J(6), Tapson V(7), Yusen RD(8), Jiménez D(5).

Author information: 
(1)F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, 
USA. (2)Department of Emergency Medicine, Indiana University School of Medicine, 
Indianapolis, Indiana, USA. (3)Department of Internal Medicine, Ramón y Cajal
Hospital and Instituto Ramón y Cajal. (4)Radiology Department, Ramón y Cajal
Hospital and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid,
Spain. (5)Respiratory Department, Ramón y Cajal Hospital, Instituto Ramón y Cajal
de Investigación Sanitaria IRYCIS, and Alcala de Henares University, Madrid,
Spain. (6)Emergency Department, Ramón y Cajal Hospital and Instituto Ramón y
Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain. (7)Divisions of Pulmonary
and Critical Care Medicine, Cedars-Sinai, Los Angeles, California, USA.
(8)Divisions of Pulmonary and Critical Care Medicine and General Medical
Sciences, Washington University School of Medicine, St. Louis, Missouri, USA.

BACKGROUND: Whether patients with a negative multidetector computed tomographic
pulmonary angiography (CTPA) and a high clinical pretest probability should be
further investigated is controversial.
METHODS: This was a prospective investigation of the sensitivity of multidetector
CTPA among patients with a priori clinical assessment of high probability of PE
according to the Wells criteria. Among patients with a negative CTPA, the
diagnosis of PE required at least one of the following conditions:
ventilation-perfusion lung scanning showing a high probability of PE in a patient
with no history of PE, abnormal findings on venous ultrasonography in a patient
without previous deep venous thrombosis at that site, or the occurrence of venous
thromboembolism (VTE) in a 3-month follow-up period after anticoagulation was
withheld because of a negative multidetector CTPA result.
RESULTS: We identified 498 patients with a priori clinical assessment of high
probability of PE and a completed CTPA study. CTPA excluded PE in 134 patients;
in these patients the pooled incidence of VTE was 5.2% (7 of 134 patients; 95%
CI, 1.5%-9.0%). Five patients had VTEs that were confirmed by an additional
imaging test despite a negative CTPA (5 of 48 patients; 10.4%; 95% CI,
1.8%-19.1%), and 2 patients had objectively confirmed VTEs that occurred during
clinical follow-up of at least 3 months (2 of 86 patients; 2.3%; 95% CI,
0%-5.5%). None of the patients had a fatal PE during follow-up.
CONCLUSIONS: A normal multidetector CTPA result alone may not safely exclude PE
in patients with a high clinical pretest probability. This article is protected
by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

PMID: 26559176  [PubMed - as supplied by publisher]

Diagnostic

1. Licht H, Murray M, Vassaur J et al. The Relationship of Obesity to Increasing Health-Care Burden in the Setting of Orthopaedic Polytrauma. J Bone Joint Surg Am. 2015 Nov 18;97(22):e73. doi: 10.2106/JBJS.O.00046.

CONCLUSIONS: Computed tomographic scans, routinely obtained at the time of admission, can be utilized to calculate truncal adiposity and to investigate the impact of obesity on patients with polytrauma. Obese patients were found to have higher total hospital charges, longer hospital stays, discharge to a continuing-care facility, and a higher rate of orthopaedic surgical intervention. PMID: 26582625

Comments: Obesity is associated with increased mortality in trauma patients.  The greater the amount of mass on abdominal CT (as a proxy for BMI), the more the problems faced in obese patients with polytrauma.  Obesity kills.

2. Karl JW, Swart E, Strauch RJ. Diagnosis of Occult Scaphoid Fractures: A Cost-Effectiveness Analysis. J Bone Joint Surg Am. 2015 Nov 18;97(22):1860-8. doi: 10.2106/JBJS.O.00099.

CONCLUSIONS: Given its relatively low cost and high diagnostic accuracy, advanced imaging for suspected scaphoid fractures in the setting of negative radiographs represents a cost-effective strategy for reducing both costs and morbidity. The decision to use CT compared with MRI is a function of individual institutional costs and local test performance characteristics. PMID: 26582616 

Comments: This was surprising to me.  When lost worker productivity and increase need for surgery in non-union were considered, it appears cost-effective to use advanced imaging in equivocal scaphoid fractures.  What is not clear is if there would be benefit in doing this in the ED vs. prompt orthopedic follow up.

Review

None

Clinical Prediction Rules

None