Diagnostic performance of Wells score combined with point-of-care lung and venous ultrasound in suspected pulmonary embolism

Objective: Lung and venous ultrasound are bedside diagnostic tools increasingly used in the early diagnostic approach of suspected pulmonary embolism (PE). However, the possibility of improving the conventional prediction rule for PE by integrating ultrasound has never been investigated. Methods: We performed lung and venous ultrasound in consecutive patients suspected of PE in four emergency departments. Conventional Wells score (Ws) was adjudicated by the attending physician, and ultrasound was performed by one of 20 investigators. Signs of deep venous thrombosis (DVT) at venous ultrasound and signs of pulmonary infarcts or alternative diagnoses at lung ultrasound were considered to recalculate two items of the Ws: signs and symptoms of DVT and alternative diagnosis less likely than PE. The diagnostic performances of the ultrasound-enhanced Ws (USWs) and Ws were then compared after confirmation of the final diagnosis. Results: A total of 446 patients were studied. PE was confirmed in 125 patients (28%). USWs performed significantly better than Ws, with a sensitivity of 69.6% versus 57.6% and a specificity of 88.2% versus 68.2%. In combination with D-dimer, USWs showed an optimal failure rate (0.8%) and a significantly superior efficiency than Ws (32.3% vs. 27.2%). A strategy based on lung and venous ultrasound combined with D-dimer would allow to avoid CT pulmonary angiography in 50.5% of patients with suspected PE, compared to 27.2% when the rule without ultrasound is applied. Conclusions: A pretest risk stratification enhanced by ultrasound of lung and venous performs better than Ws in the early diagnostic process of PE

Potentially harmful effects of inspiratory synchronization during pressure preset ventilation

Purpose: Pressure preset ventilation (PPV) modes with set inspiratory time can be classified according to their ability to synchronize pressure delivery with patient's inspiratory efforts (i-synchronization). Non-i-synchronized (like airway pressure release ventilation, APRV), partially i-synchronized (like biphasic airway pressure), and fully i-synchronized modes (like assist-pressure control) can be distinguished. Under identical ventilatory settings across PPV modes, the degree of i-synchronization may affect tidal volume (V T), transpulmonary pressure (P TP), and their variability. We performed bench and clinical studies. Methods: In the bench study, all the PPV modes of five ventilators were tested with an active lung simulator. Spontaneous efforts of −10cmH2O at rates of 20 and 30breaths/min were simulated. Ventilator settings were high pressure 30cmH2O, positive end-expiratory pressure (PEEP) 15cmH2O, frequency 15breaths/min, and inspiratory to expiratory ratios (I:E) 1:3 and 3:1. In the clinical studies, data from eight intubated patients suffering from acute respiratory distress syndrome (ARDS) and ventilated with APRV were compared to the bench tests. In four additional ARDS patients, each of the PPV modes was compared. Results: As the degree of i-synchronization among the different PPV modes increased, mean V T and P TP swings markedly increased while breathing variability decreased. This was consistent with clinical comparison in four ARDS patients. Observational results in eight ARDS patients show low V T and a high variability with APRV. Conclusion: Despite identical ventilator settings, the different PPV modes lead to substantial differences in V T, P TP, and breathing variability in the presence spontaneous efforts. Clinicians should be aware of the possible harmful effects of i-synchronization especially when high V T is undesirabl

Omalizumab : When and to whom

Immunoglobulin E plays a central role in the pathogenesis of asthma. Omalizumab is a recombinant humanised monoclonal antibody directed against Immunoglobulin E to inhibit the immune system's response to allergen exposure. Omalizumab binds to free Immunoglobulin E decreasing cell-bound Immunoglobulin E and reduces high-affinity receptors on mast cells and basophils blocking the allergic cascade at its primary step. Approximately 20% of asthma patients have severe asthma, 20% are uncontrolled and 50% have allergic asthma, and about 2% of asthmatic patients would be eligible for anti-Immunoglobulin E treatment. Uncontrolled asthma remains a major issue. In fact, despite inhaled corticosteroid (ICS) or ICS plus long-acting \u3b22-agonist therapy, 72% of patients are uncontrolled or not well controlled according to the Asthma Control Questionnaire. Omalizumab as add-on therapy reduces exacerbations, need of emergency visits and systemic steroid administration, and hospitalizations, Finally, omalizumab is generally well tolerated

Point-of-Care Lung Sonography : An Audit of 1150 Examinations

Objectives-Point-of-care lung sonography has theoretical usefulness in numerous diseases; however clinical indications and the impact of this technique have not been fully investigated. We aimed to describe the current use of point-of-care lung sonography. Methods-A 2-year prospective observational study was performed by pulmonologists in an Italian university hospital. Techniques, indications, consequences of lung sonography, and barriers to the examination were analyzed. Results-A total of 1150 lung sonographic examinations were performed on 951 patients. The most common indications were diagnosis and follow-up of pleural effusion in 361 cases (31%), evaluation of lung consolidation (322 [28%]), acute heart failure (195 [17%]), guide to pleural procedures (117 [10%]), pneumothorax (54 [5%]) and acute exacerbations of chronic obstructive pulmonary disease (30 [3%]). The mean duration of the examination6SD was 664 minutes. The transducers most frequently used were convex (746 [65%]) and linear (161 [14%]), whereas in 205 examinations (18%), both transducers were used. According to the judgment of the caring clinician, 51% of the examinations were clinically relevant. Conclusions-Point-of-care lung sonography performed by pulmonologists is quick and feasible and could be widely used for different clinical indications with a potentially high clinical impact. The widespread use of this technique may have a relevant clinical impact in several indications

The seismic vulnerability assessment of Québec churches: considerations on territorial specificities

Masonry churches have demonstrated to be vulnerable to earthquakes. The cause of such vulnerability is due to their intrinsic structural characteristics. Many examples of Italian churches could be cited to illustrate this structural vulnerability, based on the long seismic history which characterizes this territory. A series of systematic studies have been performed since the 1976 Friuli earthquake, providing methods for vulnerability assessment, identification of macro-elements and the relative kinematic mechanisms, and damage classification. In this context, the present paper focuses on some territorial aspects, such as materials and techniques of construction, common in Québec churches. They should be considered in the evaluation of the structural performance of the church building under seismic actions. The long Italian history of seismicity and damage experience provides a knowledge base useful also in another context, such as the Canadian one. In this paper, some of the most important Italian earthquakes (Friuli, 1976, Emilia-Lombardy, 2012, Central Italy, 2016) are recalled for specific aspects that were observed and that constitute an experience in the field. These aspects are useful for a preventive analysis of some churches on the Island of Montreal, in the Province of Québec, Canada. Starting from a previous seismic vulnerability study, a research is in progress aiming to identify and define regional macro-elements or mechanisms specific to those churches. An adaptation of the Italian methodology for assessing the seismic vulnerability of churches to a different context, with proper materials and techniques of construction, is proposed in this paper. This approach leads to a method for the seismic vulnerability assessment for churches, specifically related to the territory, keeping as reference the already consolidated procedure

Prediction rule for diagnosis of pulmonary embolism enhanced by lung and venous ultrasound : making confusion or increasing efficiency?

We thank the Authors for their interest in our study [1] and the questions raised. Our response begins from their conclusion: "\u2026we fear that uWells' may create more noise than signal in the already murky PE milieu". We find curious that two strongly evidence based applications of point-of-care ultrasound (POCUS) added to the clinical evaluation might create confusion rather than resolving challenging questions. This article is protected by copyright. All rights reserved