ObjectiveTo evaluate the predictive value of the high-sensitivity cardiac troponin I (hs-cTnI) in patients with acute pulmonary embolism (APE). MethodsIn a retrospective cohort study,272 consecutive patients with APE were reviewed and the 30-days death and in-hospital adverse events were evaluated. The patients were classified according to hs-cTnI value into a high hs-cTnI group and a low hs-cTnI group. The simple pulmonary embolism severity index (sPESI) was used for clinical risk determination. The adverse event was defined as intravenous thrombolytic therapy,noninvasive ventilator support to maintain oxygen saturation >90% and suffered with severe complications. The correlations of hs-cTnI with sPESI score,30-days adverse events and mortality were analyzed. The Kaplan-Meier curves and the log-rank test were used to compare time-to-event survival. Stepwise multivariate logistic regression analysis models were used to determine the incremental prognostic value of sPESI score and hs-cTnI. ResultsThe incidence of 30-day death (6.1%),renal failure (14.6%),bleeding (13.4%) and thrombolytic therapy (7.9%) were higher in the high hs-cTnI group than those in the low hs-cTnI group (P values were 0.009,<0.001,0.018 and 0.003,respectively). The patients with sPESI ≥1 and low hs-cTnI had greater free adverse events survival (P=0.005). hs-cTnI provided incremental predictive value for in-hospital adverse events,beyond the sPESI score (P<0.001). Conclusionhs-cTnI has excellent negative predictive value of APE prognosis,especially when used combined with sPESI score.
Objective To explore the clinical manifestations, computed tomography features, management and prognosis of Klebsiella pneumoniae liver abscess complicated with septic pulmonary embolism. Methods The clinical data of patients with Klebsiella pneumoniae liver abscess complicated with septic pulmonary embolism admitted to Dongnan Hospital of Xiamen University from January 2012 to January 2017 were retrospectively analyzed. Results There were 8 patients who had Klebsiella pneumoniae liver abscess complicated with septic pulmonary embolism. Fever occurred in all patients, respiratory symptoms were noted in 5 patients, abdominal pain occurred in 2 patients, endophthalmitis coexisted in 1 patient, and diabetes mellitus coexisted in 7 patients, with no chest pain or hemoptysis. In biochemical indexes, procalcitonin increased most obviously. Microbiological studies revealed Klebsiella pneumoniae in 8 patients. Chest CT showed peripheral nodules with or without cavities, peripheral wedge-shaped opacities, a feeding vessel sign, pleural effusion, and infiltrative shadow. One patient finally deteriorated to acute respiratory failure, and died due to acute respiratory distress syndrome and/or septic shock. There was one case of spontaneous discharge. A total of 6 patients were improved and cured. Conclusions The clinical manifestation of Klebsiella pneumoniae liver abscess complicated with septic pulmonary embolism is unspecific and misdiagnosis rate is relatively high. The major characteristics of chest CT scan include peripheral nodules with or without cavities, peripheral wedge-shaped opacities and a feeding vessel sign. Diagnosis and differential diagnosis can be made based on these features combined with clinical data and primary disease (liver abscess).
Objective To investigate the risk factors, clinical characteristics and prognostic factors of venous thrombosis (and pulmonary embolism) in patients with idiopathic hypereosinophilia (IHE) so as to provide a theoretical basis for clinical prevention of venous thrombosis and improve prognosis.Methods Thirty-nine patients with IHE admitted to West China Hospital of Sichuan University from January 2010 to January 2022 were collected in this retrospective case-control study to explore the risk factors of venous thrombosis (including pulmonary embolism) and thrombosis recurrence after treatment. Results There were 17 (43.5%) patients combined with venous thrombosis of 39 patients with IHE. In the patients with vascular involvement, pulmonary embolism was the initial expression of IHE accounted for 29% (5/17). patients of IHE with pulmonary embolism were younger [44 (24.5 - 51.0) vs. 56 (46.3 - 67.8) year, P=0.035] and had higher peak absolute eosinophil counts [11.7 (7.2 - 26.5)×109/L vs. 3.8 (2.9 - 6.7)×109/L, P=0.020] than those without pulmonary embolism. After a mean follow-up of 13 months (2 - 21 months), thrombosis recurred in 35.3% (6/17) of patients. Persistent increasing in eosinophils (>0.5×109/L) was an independent risk factor for thrombus recurrence (odds ratio 13.33, 95% confidential interval 1.069 - 166.374). Conclusions Thrombosis is a common vascular impaired complication in IHE , and increased eosinophilia is a risk factor for thrombosis and thrombus recurrence after therapy. Controlling and monitoring the eosinophilic cell levels in patients with IHE may avoid severe comorbidities.
Objective To compare the prognostic value of different types of simplified Pulmonary Embolism Severity Index (sPESI) in patients with acute pulmonary embolism (APE), so as to select the best scoring system for clinical application. Methods We retrospectively collected the data of consecutive patients with APE in the Fourth People’s Hospital of Zigong City from January 1st, 2014 to January 1st, 2019. The endpoint was 1-month all-cause mortality. We tried to modify sPESI by replacing arterial oxyhaemoglobin saturation with arterial partial pressure of oxygen / fraction of inspired oxygen (new scoring system named psPESI), and modify sPESI by replacing arterial oxyhaemoglobin saturation with saturation of pulse oxygen / fraction of inspired oxygen (new scoring system named ssPESI), and analyzed the area under the receiver-operating characteristic curve (AUC), net reclassification improvement (NRI), integrated discrimination improvement (IDI), calibration and decision curve. Results A total of 280 patients (109 with low-risk APE, 155 with intermediate-risk APE, and 16 with high-risk APE) were enrolled in the study. Of these patients, 165 (58.93%) were male, and the 1-month all-cause mortality rate was 10.71% (30/280). The AUCs of sPESI, psPESI and ssPESI were 0.756, 0.822 and 0.807, respectively, and the AUC of ssPESI was higher than that of sPESI (P=0.038) but not lower than that of psPESI (P=0.388). Comparing ssPESI with sPESI, the NRI was 0.928 (P<0.001) and the IDI was 0.084 (P<0.001); comparing ssPESI with psPESI, the NRI was 0.041 (P=0.227) and the IDI was –0.028 (P=0.060). The psPESI (Hosmer-Lemeshow test χ2=12.591, P=0.182) and ssPESI (Hosmer-Lemeshow test χ2=4.204, P=0.897) were well-calibrated in the internal validation cohort and obtained more net benefits within wide threshold probabilities than sPESI. Conclusion Since the saturation of pulse oxygen is non-invasive and easy to obtain, and the predictive ability of ssPESI is similar to that of psPESI, it is recommended that ssPESI be used as a new scoring system to evaluate the prognosis of APE.
Objective To analyze the clinical features of rickettsial infection complicated with pulmonary embolism and to improve clinicians’ knowledge of rickettsial infection complicated by thromboembolism events. Methods We retrospectively analyzed the clinical data of a patient with pulmonary thromboembolism complicated by Rickettsial felis infection and conducted a review of the relevant literature. The search terms "Rickettsia/Scrub typhus, thrombosis" or "Rickettsia/ Scrub typhus, embolism" were used to search the Wanfang ,VIP ,Chinese National Knowledge Infrastructure and PubMed databases from January 1985 to May 2023, respectively. Results The 81-year-old male patient was admitted to the hospital on June 1, 2021 due to "dizziness, sore throat for 11 days, fever for 7 days, and shortness of breath for 3 days". Physical examination revealed a eschar-like rash behind the left ear, venous thrombosis in both lower limbs was detected by color ultrasound, computed tomographic pulmonary angiography indicated multiple pulmonary embolism in both lungs, and positive rickettsiae on peripheral blood next-generation sequencing, confirming the diagnosis of Rickettsial felis infection complicated by venous thromboembolism (VTE) in both lower limbs and pulmonary embolism. Twenty manuscripts, including 20 cases, were retrieved from databases. Among them, Rickettsial felis infection combined with thromboembolism event was not found. With the addition of our case, a total of 21 cases were analyzed in detail. Six of the 21 cases were complicated with VTE, 10 with pulmonary embolism, 5 with intracranial venous thrombosis, 6 with thrombosis at other sites (jugular venous thrombosis, mesenteric thrombosis, aortic thrombosis, etc), and 8 of which had concurrently involved systemic thrombosis. Of the 4 deaths, 2 cases had mesenteric embolism, 1 case had cerebral infarction, and 1 case had systemic multiple thrombus. Conclusions Rickettsial infection symptoms and signs are often atypical, can be complicated with lower limb VTE or pulmonary embolism. Early identification, diagnosis and treatment are very important, especially for patients with dyspnea, chest pain and other related symptoms.
ObjectiveTo explore the diagnostic value of the bedside echocardiogram for different risk stratification of patients with suspected pulmonary embolism. MethodsPatients with suspected pulmonary embolism in the emergency department of the Second Afflicted Hospital Xi'an Jiaotong University between July 2013 to December 2015 were included. According the Wells scores, they were divided into a low risk group (0-2 points), a intermediate risk group (3-6 points) and a high risk group (>6 points). All patients were underwent the bedside echocardiogram diagnosis, and the diagnostic value of the echocardiography for pulmonary embolism, the characteristics of different risk stratification of patients were analyzed by SPSS 18.0 software. Results115 patients with suspected pulmonary embolism were included, of which 20 were in the low risk group, 73 were in the medium risk group, and 22 were in the high risk group. The incidence of pulmonary embolism among the three groups was significantly different (high-risk vs. medium risk vs. low-risk: 90.9% vs. 76.7% vs. 15.0%, P<0.05), and the higher Wells scores gets, the greater possibility of having the pulmonary embolism. For the intermediate-risk group, the incidence of pulmonary embolism was significantly higher in patients with positive ultrasonic results than those with the negative ultrasonic results (87.3% vs. 44.4%, P<0.05). The predication of the ultrasonic positive and the negative in the low and high risk groups had no statistical differences (P>0.05). The result of echocardiogram showed that the right ventricular end-diastolic diameter, right ventricular end-diastolic transverse diameter, right atrial end-diastolic transverse diameter, RV/LV, RA/LA in the high risk group and the intermediate risk group were significantly higher than those in the low risk group (all P values <0.05). The right ventricular anterior wall activity in the low risk group was higher than that in the high risk group (P<0.05), but this difference was not found between the high risk group and the intermediate risk group. ConclusionBedside echocardiogram can be used as the diagnosis and differential diagnosis methods of suspected pulmonary embolism, and it has relatively higher diagnostic value for intermediate to high risk patients predicted by the Wells scores than low risk ones.
Objective To investigate the clinical characteristics and diagnosis and treatment of fungal pulmonary embolism, and to improve the understanding of this disease. Methods The diagnosis and treatment of two patients with fungal main pulmonary embolism in the First Affiliated Hospital of Guangzhou Medical University were summarized and analyzed. Literatures were retrieved from Wanfang database, China national knowledge internet database and Pubmed database with search terms of “pulmonary embolism AND mucor”, “pulmonary embolism AND aspergillus”, “pulmonary embolism AND fungi”, “pulmonary embolism AND Candida”, “pulmonary embolism AND cryptococcus”. Results Case 1, a 53-year-old female was referred, with cough, high fever, breathlessness for 2 years, chest pain for 1 year. The patient had rheumatoid arthritis and systemic lupus erythematosus history with long term prednisone treatment. Finally, the patient was diagnosed main pulmonary artery embolism (aspergillus) and disseminated aspergillosis. Although treatment with voriconazole, amphotericin B, and caspofungin were given for more than 1 year, the patient died with uncontrolled aspergillus infection. Case 2, a 67-year-old female was referred with cough, chest distress, chest pain for 8 months, breathlessness for 6 months. The patient had a history of chronic viral hepatitis C. Finally the patient was diagnosed as main pulmonary artery embolism and pulmonary valve endocarditis (aspergillus, mucor). The patient underwent pulmonary artery lesion resection and tricuspid valvuloplasty (DeVega method). After surgery, the patient was delivered with amphotericin B and posaconazole for 3 months. During the follow-up period of 1 year, the patient recovered almost totally without relapse signs. A total of 42 cases of fungal pulmonary embolism from 1980 to 2021 were retrieved (including 2 cases in this article), and 6 of these cases were main pulmonary artery embolism. Of all the cases, the median age was 49 years and 22 (54.3%) were males. 20 cases were immunocompromised. The infection pathogens included: Aspergillus (21, 50%), Candida (11, 26.2%), Mucor (7, 16.7%), and Aspergillus combined with Mucor (1, 2.5%), Coccidioides spp (1, 2.5%), and Cryptococcus (1, 2.5%). Fifteen cases were complicated with infection other than cardiopulmonary. Twenty-two cases were treated with surgery combined with antifungal medicine, and 9 cases with antifungal medicine alone. Twenty-two cases were dead and the overall mortality rate was 52.4%. There were statistically significant differences in the effects of fungal species, dissemination of other organs other than the heart and lung, and surgical treatment on the survival rate. The survival rate of different fungal species was significantly different. Dissemination to organs other than the heart and lungs reduces survival, whereas surgical treatment improves survival. Conclusions Fungal pulmonary embolism, a disease with high mortality, rarely involves the main pulmonary artery. The possibility of fungal pulmonary embolism should be considered when the cause of pulmonary thrombosis is unknown and the anticoagulant effect is poor. Although there is no unified treatment at present, early surgical combined with standard antifungal treatment may improve the prognosis of patients.
Aortic intramural hematoma and pulmonary embolism are two rapidly progressive and life-threatening diseases. A 65-year-old male patient with descending aortic intramural hematoma and pulmonary embolism underwent pulmonary embolectomy and descending aortic stent-graft placement, with good postoperative results.
ObjectiveTo explore the early predictive value of Wells score and D-dimer for acute pulmonary embolism. MethodsEighty-two cases with acute pulmonary embolism comfirmed by computed tomography pulmonary angiography and (or) lung ventilation/perfusion scan were retrospectively studied from October 2013 to October 2014 in our hospital. Another 82 cases without acute pulmonary embolism in the chest pain center simultaneously were selected as control group. The data on admission were analyzed including Wells score, D-dimer, pH, PCO2, PO2, P(A-a)O2, brain natriuretic peptide, troponin I of two groups of patients. Relevant variables were selected by multivariate logistic regression analysis. The receiver operating characteristic (ROC) curve was made by sensitivity as the ordinate and 1 minus specificity as abscissa. The area under ROC curve (AUC) for relevant variables was calculated and the variable with higher AUC was selected. The best threshold, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were achieved from the ROC curves. ResultsThe multivariate logistic regression analysis showed that Wells score (OR=8.114, 95%CI 1.894-34.761, P=0.005) and D-dimer (OR=1.009, 95%CI 1.001-1.017, P=0.021) could predict APE early. The AUC, sensitivity, specificity, PPV, NPV of Wells score for the early prediction of patients with acute pulmonary embolism were 0.990, 50.0%, 100.0%, 100.0%, 66.7%, respectively. The AUC, sensitivity, specificity, PPV, NPV of D-dimer for the early prediction of patients with acute pulmonary embolism were 0.986, 95.1%, 97.6%, 97.5%, 95.2%, respectively. ConclusionWells score and D-dimer have high predictive value in patients with acute pulmonary embolism, and can be used in preliminary screening of acute pulmonary embolism in the emergency department.
Objective To investigate the value of fibrinogen to albumin ratio (FAR) combined with pulmonary embolism severity index (PESI) in the assessment of severity and prognosis of patients with acute pulmonary thromboembolism (APTE). Methods A retrospective study of hospitalized patients with confirmed APTE admitted to the Affiliated Hospital of Southwest Medical University from September 2013 to August 2021, divided into low-risk, intermediate-risk, and high-risk groups according to the Guidelines for the Diagnosis, Treatment and Prevention of Pulmonary Thromboembolism, and divided into survival groups and death groups according to the 30-day prognosis. The general data of all patients and relevant blood laboratory tests within 2 hours after admission were collected to calculate PESI and FAR. FAR and PESI levels were compared in APTE patients with different severity of disease and different prognosis. Independent risk factors for 30-day mortality in APTE patients were analyzed using logistic regression. Subject working characteristic curves were drawn to assess the differences in sensitivity, specificity and area under the curve of FAR, PESI and FAR combined with PESI in predicting 30-day death. Results Total of 235 APTE patients were included, divided into 85 in the low-risk group, 110 in the intermediate-risk group, and 40 in the high-risk group; 192 in the survival group and 43 in the death group according to 30-day survival. The differences in age, albumin (ALB), high-sensitivity troponin, D-dimer, fibrinogen (FIB), FAR, and PESI of APTE patients with different disease severity were statistically significant (P<0.05). FAR increased progressively with increasing severity of disease (P<0.05), and correlation analysis showed a positive correlation between FAR and PESI (r=0.614, P<0.05). Elevated FIB, FAR, PESI and decreased ALB were independent risk factors for 30-day death in patients with APTE (P<0.05). FAR, PESI, and FAR combined with PESI all had predictive value for 30-day death in APTE patients, and FAR combined with PESI predicted the largest area under the 30-day death curve. Conclusions FAR correlated with the severity and prognosis of APTE patients. FAR combined with PESI was more valuable in assessing the 30-day prognosis of APTE patients than FAR alone or PESI alone.