1/4. Does this patient have pulmonary embolism?CONTEXT: Experienced clinicians' gestalt is useful in estimating the pretest probability for pulmonary embolism and is complementary to diagnostic testing, such as lung scanning. However, it is unclear whether recently developed clinical prediction rules, using explicit features of clinical examination, are comparable with clinicians' gestalt. If so, clinical prediction rules would be powerful tools because they could be used by less-experienced health care professionals to simplify the diagnosis of pulmonary embolism. Recent studies have shown that the combination of a low pretest probability (using a clinical prediction rule) and a normal result of a D-dimer test reliably excludes pulmonary embolism without the need for further testing. OBJECTIVE: To evaluate and demonstrate the accuracy of pretest probability assessment for pulmonary embolism using clinical gestalt vs clinical prediction rules. DATA SOURCES: The medline database was searched for relevant articles published between 1966 and March 2003. Bibliographies of pertinent articles also were scanned for suitable articles. STUDY SELECTION: To be included in the analysis, studies were required to have consecutive, unselected patients enrolled; participating physicians in the studies, blinded to the results of diagnostic testing, had to estimate pretest probability of pulmonary embolism; and validated diagnostic methods had to be used to confirm or exclude pulmonary embolism. DATA EXTRACTION: Three reviewers independently scanned titles and abstracts for inclusion of studies. An initial medline search identified 1709 studies, of which 16 involving 8306 patients were included in the final analysis. DATA SYNTHESIS: A clinical gestalt strategy was used in 7 studies, and in the low, moderate, and high pretest categories, the rates of pulmonary embolism ranged from 8% to 19%, 26% to 47%, and 46% to 91%, respectively. Clinical prediction rules were used in 10 studies, and 3% to 28%, 16% to 46%, and 38% to 98% in the low, moderate, and high pretest probability groups, respectively, had pulmonary embolism. CONCLUSIONS: The clinical gestalt of experienced clinicians and the clinical prediction rules used by physicians of varying experience have shown similar accuracy in discriminating among patients who have a low, moderate, or high pretest probability of pulmonary embolism. We advocate the use of a clinical prediction rule because it has shown to be accurate and can be used by less-experienced clinicians.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
2/4. dyspnea during thalidomide treatment for advanced ovarian cancer.OBJECTIVE: To detail the dyspnea encountered in women receiving thalidomide as therapy for advanced ovarian cancer. CASE SUMMARIES: Eight of 18 (44%) patients with recurrent ovarian cancer developed dyspnea while receiving thalidomide 200 mg daily as part of a prospective Phase II study. dyspnea was evaluated with pulse oximetry, chest X-ray and, if indicated, spiral computed tomography scan. Four patients had abnormal chest X-ray findings (1 pleural effusion, 1 pneumonia, 2 mild congestive heart failure), and one of these patients also had a pulmonary embolus. The other 4 patients had no objective test findings to explain their dyspnea. Five patients had resolution of symptoms when thalidomide was discontinued and, when the drug was resumed at a 50% dose reduction, experienced no further shortness of breath. DISCUSSION: While dyspnea in association with thalidomide has not previously been reported as a common adverse event, it was a frequent complaint of patients receiving this drug as part of a Phase II study. Comorbid conditions causing dyspnea were evaluated since they are common in this patient population; however, half of our patients had no objective evidence of such conditions. The Naranjo probability scale indicated a probable relationship between dyspnea and thalidomide therapy in the patients with no objective evidence of comorbidity. We advocate discontinuation of thalidomide until symptoms have resolved, at which time reintroduction of thalidomide at a reduced dose may be considered. CONCLUSIONS: patients receiving thalidomide may develop dyspnea as an adverse effect of the drug. In selected patients, thalidomide may be safely reintroduced once symptoms resolve.- - - - - - - - - - ranking = 0.16666666666667keywords = probability (Clic here for more details about this article) |
3/4. Cardiopulmonary thromboembolism detected by Tc-99m MH-1 antifibrin antibody.A patient with shortness of breath had a high probability lung scan for pulmonary embolism, but no obvious embolic source. Whole-body scintigraphy using Tc-99m labeled Fab' antifibrin monoclonal antibody showed large central pulmonary emboli as well as tracer uptake in the right atrium and aortic arch. No lower extremity clot was detected. This case shows significant differences in the appearance of pulmonary embolism as assessed by direct clot and ventilation-perfusion scintigraphy. It shows the importance of the heart as the origin of pulmonary emboli and the utility of direct thrombus visualization.- - - - - - - - - - ranking = 0.16666666666667keywords = probability (Clic here for more details about this article) |
4/4. Pulmonary tumor microembolism.Pulmonary tumor embolism is an often missed antemortem diagnosis in patients with cancer and respiratory failure. Although rare, this complication is an important cause of additional morbidity. Referred for radionuclide pulmonary perfusion and ventilation scintigraphy, a typical pattern of multiple subsegmental peripheral defects on perfusion lung scanning without matching ventilation defects, suggesting a high probability of pulmonary thromboembolism, often leads to false conclusions. We present a case of bilateral multiple subsegmental mismatched defects in lung ventilation perfusion scintigraphy, where autopsy confirmed the diagnosis of pulmonary tumor embolism, secondary to an undifferentiated ductal type adenocarcinoma of the pancreas. Pulmonary tumor embolism is an entity to keep in mind in patients treated for carcinoma presenting with (sub) acute dyspnea.- - - - - - - - - - ranking = 0.16666666666667keywords = probability (Clic here for more details about this article) |