Overdiagnosis of Pulmonary Embolism: Evaluation of a Hypoxia Algorithm Designed to Avoid This Catastrophic Problem

Winters, Brian S.; Solarz, Mark K.; Jacovides, Christina; Purtill, James J.; Rothman, Richard H.; Parvızı, Javad

doi:10.1007/s11999-011-2109-2

Cited by 21 publications

(13 citation statements)

References 16 publications

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“…The incidence of symptomatic PE, symptomatic DVT, wound complications (hematoma formation, acute infection [within 30 days postoperatively], prolonged wound drainage), and mortality were collected. Investigation for symptomatic PE followed our institutional protocol [42]. Patients exhibiting signs and symptoms of tachypnea, dyspnea, new onset arrhythmia, tachycardia, chest pain, or hemoptysis were assessed with pulse oximetry, vital signs, an ECG, a chest radiograph, and a set of cardiac enzymes.…”

Section: Methodsmentioning

confidence: 99%

Aspirin: An Alternative for Pulmonary Embolism Prophylaxis After Arthroplasty?

Raphael

Tischler

Huang

et al. 2013

Clin Orthop Relat Res

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Background The most effective agent for prophylaxis against venous thromboembolic disease after total joint arthroplasty (TJA) remains unknown. The paucity of literature comparing different methods of pulmonary embolism (PE) prophylaxis and fear of litigation make it difficult for surgeons to abandon the use of aggressive chemical prophylaxis. Questions/purposes We compared the (1) overall frequency of symptomatic PE, (2) risk of symptomatic PE after propensity matching that adjusted for potentially confounding variables, and (3) other complications and length of stay before and after propensity matching in patients undergoing TJA at our institution who received either aspirin or warfarin prophylaxis. Methods A total of 28,923 patients underwent TJA between

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Section: Methodsmentioning

confidence: 99%

Aspirin: An Alternative for Pulmonary Embolism Prophylaxis After Arthroplasty?

Raphael

Tischler

Huang

et al. 2013

Clin Orthop Relat Res

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“…This is called overdiagnosis and overtreatment of PE [17]. Other authors see a catastrophic problem [18].…”

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confidence: 99%

Perfusion SPECT in patients with suspected pulmonary embolism: how much sensitivity is needed to keep patients alive?

Schuemichen

2013

Eur J Nucl Med Mol Imaging

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Combined use of ventilation (V) and perfusion (P) scintigraphy for the diagnosis of acute and chronic thromboembolic pulmonary embolism (PE) has been well established for nearly 50 years, and is also anchored in the current European guidelines [1,2]. The intention in using this technique is to differentiate between local V/P mismatch associated with embolic disease and local V/P match related to obstructive airway disease. This functional approach to the diagnosis of PE is needed mostly in elderly patients, since the incidence of obstructive airway disease increases with age. With Ponly scintigraphy the rate of false-positive findings increases to an unacceptable 47 % even with SPECT/CT [3]. Despite well-documented advantages, V scintigraphy has not become popular in many European countries for various reasons: availability (Italy), expense, fear of radioactive contamination, and lack of quality control (Germany).In 2005, P-only scintigraphy was performed in 89 % of all lung examinations in Italy, in 72.4 % in Germany, in 44.1 % in Spain, in 21.3 % in the UK, and in only 12.4 % in France [4]. Proof or exclusion of PE was intended in most of these studies. Two years later, following the success of CT pulmonary angiography (CTPA), the number of V scintigraphies in Germany increased by 25 %, but lung examinations went down by 37 %. In Italy, morphological attributes (PISA-PED criteria) as a substitute for V scintigraphy have been added to reduce false-positive results from P-only planar scintigraphy. Single or multiple wedge-shaped P defects, with or without matching chest roentgenographic abnormalities, are reported as PE-positive. Wedge-shaped areas of overperfusion usually coexist. P defects other than wedgeshaped are PE-negative. With pulmonary angiography as reference, the P lung scan has been shown to have a sensitivity of 92 % and a specificity of 87 % in the diagnosis of PE [5]. Compared to CTPA and also V/P planar scintigraphy with PIOPED II interpretation together with chest radiography, the sensitivity of P-only planar scintigraphy with PISA-PED interpretation is somewhat below 90 %, but diagnostic accuracy is remarkably similar [6]. Applying V/P SPECT as reference, with interpretation criteria of the European guidelines, the sensitivity of P-only SPECT with PISA-PED interpretation criteria rose to an acceptable 90 %, and specificity to a fantastic 98 %. Segmental pneumonia was mentioned as a cause of false-positive findings, which could have been identified on a chest radiograph or more easily by SPECT/CT. These very promising results may be misinterpreted as an invitation to get rid of unpopular V scintigraphy.From our own experience it seems reasonable that the appearance of secondary perfusion defects in chronic obstructive airway disease (COPD) at the lobar and segmental level may be irregular and does not follow the lobar and segmental anatomy with a frequency that, if need be, is sufficient for diagnosis of PE. However, perfusion defects at the subsegmental level are mostly not distinguishable in ...

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“…T pulmonary angiography (CTPA) has become the accepted standard for the evaluation of a patient with suspected pulmonary embolism (PE) [3,7]. The test is fast, relatively inexpensive, and believed to be even more sensitive (and better overall) than conventional pulmonary angiography with plain radiography -once considered the gold standard for evaluating suspected PE.…”

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confidence: 99%

“…We still do not know when to order this test, or which CTPA findings deserve our worry (and our interventions). Preliminary work has been performed in orthopaedic populations [7] to try to obtain these answers, but we know much less than we need to know to do a good job for our patients when it comes to PE.…”

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confidence: 99%

“…Algorithms have been developed to try to identify high-risk patients and reduce the harm of overtreatment. A group from the Rothman Institute in Philadelphia published an algorithm designed to identify patients clinically at high-risk for PE and increase the threshold at which a CTPA was ordered [7]. They reduced the number of patients worked up for hypoxia with CTPA, and increased the number of positive findings per PE workup, without increasing mortality rates.…”

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confidence: 99%

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