Search

Background Optimal risk stratification of unsuspected pulmonary embolism (UPE) in ambulatory cancer patients (ACPs) remains unclear. Existing clinical predictive rules (CPRs) are derived from retrospective databases and have limitations. The UPE registry is a prospective international registry with pre-specified characteristics of ACPs with a recent UPE. The aim of this study was to assess the utility of risk factors captured in the UPE registry in predicting proximate (30-, 90- and 180-day) mortality and how they performed when applied to an existing CPR. Objectives To evaluate risk factors for proximate mortality, overall survival, recurrent venous thromboembolism and major bleeding, in the patients enrolled in the UPE registry cohort. Methods Data from the 695 ACPs in this registry were subjected to multivariate logistic regression analyses to identify predictors independently associated with proximate mortality and overall survival. The most consistent predictors were applied to the Hull CPR, an existing 5-point prediction rule. Results The most consistent predictors of mortality were patient-reported respiratory symptoms within 14 days before, and ECOG performance status at the time of UPE. These predictors applied to the Hull-CPR produced a consistent correlation with proximate mortality and overall survival (area under the curve [AUC] = 0.70 [95% CI 0.63, 077], AUC = 0.65 [95% CI 0.60, 070], AUC = 0.64 [95% CI 0.59, 068], and AUC = 0.61, 95% CI 0.57, 0.65, respectively). Conclusion In ACPs with UPE, ECOG performance status logged contemporaneously to the UPE diagnosis and respiratory symptoms prior to UPE diagnosis can stratify mortality risk. When applied to the HULL-CPR these risk predictors confirmed the risk stratification clusters of low-intermediate and high-risk for proximate mortality as seen in the original derivation cohort.

In orbital reconstruction, the acquired position of an orbital implant can be evaluated with the aid of intraoperative navigation. Feedback of the navigation system is only obtained after positioning of the implant: the implant's position is not tracked in real time during positioning. The surgeon has to interpret the navigation feedback and translate it to desired adjustments of the implant's position. In a previous study, a real-time implant-oriented navigation approach was introduced and the system's accuracy was evaluated. In this study, this real-time navigation approach was compared to a marker-based navigation approach in a preclinical set-up. Ten cadavers (20 orbital defects) were reconstructed twice, by two surgeons (total: 80 reconstructions). Implant positioning was significantly improved in the real-time implant-oriented approach in terms of roll (2.0° vs. 3.2°, P = 0.03), yaw (2.2° vs. 3.4°, P = 0.01) and translation (1.3 mm vs. 1.8 mm, P = 0.005). Duration of the real-time navigation procedure was reduced (median 4.5 min vs. 7.5 min). Subjective appreciation of the navigation technique was higher for real-time implant-oriented navigation (mean 7.5 vs. 9.0). Real-time implant-oriented navigation feedback provides real-time, intuitive feedback to the surgeon, which leads to improved implant positioning and shortens duration of the navigation procedure.

BACKGROUND: During the initial assessment of patients with potential severe injuries, radiological examinations are performed in order to rapidly diagnose clinically relevant injuries. Previous studies have shown that performing these examinations routinely is not always necessary and that trauma patients are exposed to substantial radiation doses. The aim of this study was to assess the amount and findings of radiological examinations during the initial assessment of trauma patients and to determine the radiation doses to which these patients are exposed to. METHODS: We analyzed the 1124 patients included in a randomized trial. All radiological examinations during the initial assessment (i.e., primary and secondary survey) were assessed. The examination results were categorized as positive findings (i.e., (suspicion for) traumatic injury) and normal findings. The effective radiation doses for the examinations were calculated separately for each patient. RESULTS: Eight hundred and three patients were male (71 %), median age was 38 years, and 1079 patients sustained blunt trauma (96 %). During initial assessment, almost 3900 X-rays were performed, of which 25.4 % showed positive findings. FAST of the abdomen was performed in 989 patients (88 %), with positive findings in 10.6 %. Additional CT scanning of specific body regions was performed 1890 times in 813 patients (72.1 %), of which approximately 43.4 % revealed positive findings. Hemodynamically stable patients showed more normal findings on the radiographic studies than unstable patients. The mean radiation doses for the total population was 8.46 mSv (±7.7) and for polytraumatized patients (ISS ≥ 16) 14.3 mSv (±9.5). CONCLUSION: Radiological diagnostics during initial assessment of trauma patients show a high rate of normal findings in our trauma system. The radiation doses to which trauma patients are exposed are considerable. Considering that the majority of the injured patients are hemodynamically stable, we suggest more selective use of X-ray and CT scanning.

Acute pulmonary embolism is one of the leading causes of maternal death, with the overall incidence reported to be 1.72 cases per 1000 deliveries, accounting for approximately 1 death in every 100,000 deliveries. Since the D-dimer test has low specificity and sensitivity, it is common for pregnant women with suspected pulmonary embolism to undergo computed tomography (CT) pulmonary angiography or ventilation-perfusion (V/Q) scanning, both of which involve radiation exposure to the mother and fetus. It is unknown whether a pregnancy-adapted clinical screening algorithm could be used to safely avoid diagnostic imaging in a subset of pregnant women with suspected pulmonary embolism. The researchers performed a multicenter, international, prospective study of pregnant women with suspected pulmonary embolism. They assessed 3 criteria from the YEARS algorithm (clinical signs of deep vein thrombosis, hemoptysis, and pulmonary embolism as the most likely diagnosis) and measured the D-dimer level as components of the screening algorithm. Pulmonary embolism was ruled out if none of the 3 criteria were met and the D-dimer level was less than 1000 ng/mL, or if 1 or more of the 3 criteria were met and the D-dimer level was less than 500 ng/mL. Adaptation of the YEARS algorithm for pregnant women involved compression ultrasonography for women with symptoms of deep vein thrombosis; if the results were positive (ie, a clot was present), CT pulmonary angiography was not performed. All patients in whom pulmonary embolism had not been ruled out by screening criteria underwent CT pulmonary angiography. The primary outcome was the incidence of venous thromboembolism (VTE) at 3 months. The secondary outcome was the proportion of patients in whom CT pulmonary angiography was not indicated to safely rule out pulmonary embolism. A total of 510 women were screened, of whom 12 (2.4%) were excluded. Pulmonary embolism was diagnosed in 20 patients (4.0%) at baseline. During follow-up, popliteal deep vein thrombosis was diagnosed in 1 patient (0.21%; 95% confidence interval, 0.0%–1.2%); no patient had pulmonary embolism. CT pulmonary angiography was not indicated, and thus was avoided, in 195 patients (39%; 95% confidence interval, 35%–44%). The efficiency of the algorithm was highest during the first trimester of pregnancy and lowest during the third trimester; CT pulmonary angiography was avoided in 65% of patients who began the study in the first trimester and in 32% who began the study in the third trimester. The researchers concluded that the pregnancy-adapted YEARS diagnostic algorithm safely ruled out acute pulmonary embolism in pregnant patients who were referred for suspected pulmonary embolism. Using this approach, they found that the main advantage was that CT pulmonary angiography was averted in 32% to 65% of the patients, depending on the trimester of presentation, without compromising safety.

Background: A major adverse effect of intravascularly administrated iodinated contrast medium is contrast-induced nephropathy (CIN). To reduce CIN incidence, two different prevention guidelines have been introduced in the Netherlands. Objective: Our goal was to assess the use of CIN prevention guidelines at the radiology departments in Dutch hospitals. Methods: We conducted a survey in all 90 Dutch hospitals with a radiology department. The questionnaire included questions about guideline execution (e.g. which guideline, (compliance) problems). Results: All responding (67/90) hospitals used a CIN prevention guideline. When asked who was responsible for conducting preventive measures in high-risk patients identified according to either guideline, the referring physician was responsible in 38 hospitals (56.7%); in 23 hospitals (34.3%) there was a specialised CIN outpatient clinic. Renal function was routinely checked after exposure to intravenous iodinated contrast medium in all CIN outpatient clinics (23) and radiology departments (2) when these were responsible for this measurement and in 52.6% (18/38) hospitals when the referring physicians were responsible. When asked if identifying patients at risk caused any problems, 47.8% reported problems. Conclusion: In all responding Dutch hospitals a CIN prevention guideline was used. There was considerable variation in the execution of the guidelines and there were substantial compliance problems. The follow-up procedure was more consistent in hospitals with an outpatient clinic