Diagnostic yield of CT thorax angiography in patients suspected of pulmonary embolism: independent predictors and protocol adherence

OBJECTIVES: To determine the diagnostic yield of computed tomography scanning of the pulmonary arteries (CTPA) in our centre and factors associated with it. Differences between specialties as well as adherence to protocol were investigated. METHODS: All patients receiving a first CTPA for pulmonary embolism (PE) in 2010 were included. Data about relevant clinical information and the requesting specialty were retrospectively obtained. Differences in diagnostic yield were tested using a chi-squared test. Independent predictors were identified with multivariate logistic regression. RESULTS: PE on CTPA was found in 224 of the 974 patients (23 %). Between specialties, diagnostic yield varied from 19.5 to 23.9 % (p = 0.20). Independent predictors of diagnostic yield were: age, sex, D-dimer, cough, dyspnea, cardiac history, chronic obstructive pulmonary disease (COPD), atelectasis/consolidation, intrapulmonary mass and/or interstitial pulmonary disease on CT. Wells scores were poorly documented (n = 127, 13.0 %). Poor adherence to protocol was also shown by a high amount of unnecessary D-dimer values with a high Wells-score (35 of 58; 58.6 %). CONCLUSIONS: The diagnostic yield of CTPA in this study was relatively high in comparison with other studies (6.7–31 %). Better adherence to protocol might improve the diagnostic yield further. A prospective study could confirm the independent predictors found in this study. TEACHING POINTS: • Pulmonary embolism is potentially life-threatening and requires quick and reliable diagnosis. • Computed tomography of the pulmonary arteries (CTPA) provides this reliable diagnosis. • Several independent predictors of diagnostic yield of CTPA for pulmonary embolism were identified. • Diagnostic yield of CTPA did not differ between requesting specialties in our Hospital. • Better protocol adherence could improve the diagnostic yield of CTPA for pulmonary embolism

Promoting Functional Health in Midlife and Old Age: Long-Term Protective Effects of Control Beliefs, Social Support, and Physical Exercise

Previous studies have examined physical risk factors in relation to functional health, but less work has focused on the protective role of psychological and social factors. We examined the individual and joint protective contribution of control beliefs, social support and physical exercise to changes in functional health, beyond the influence of health status and physical risk factors in middle-aged and older adults. Given that functional health typically declines throughout adulthood, it is important to identify modifiable factors that can be implemented to maintain functioning, improve quality of life, and reduce disability.We conducted a national longitudinal study, Midlife in the United States (MIDUS), with assessments in 1995-1996 and 2004-2006, and 3,626 community-residing adults, aged 32 to 84, were included in the analyses. Functional health (Physical Functioning subscale of the SF-36) and protective factors were measured at both occasions. While controlling for socio-demographic, health status, and physical risk factors (large waist circumference, smoking, and alcohol or drug problems), a composite of the three protective variables (control beliefs, social support, and physical exercise) at Time 1 was significantly related to functional health change. The more of these factors at Time 1, the better the health maintenance over 10 years. Among middle-aged and older adults, declines in health were significantly reduced with an increased number of protective factors.Age-related declines in health were reduced among those with more protective factors up to a decade earlier in life. Modifiable psychological, social, and physical protective factors, individually and in the aggregate, are associated with maintenance of functional health, beyond the damaging effects of physical risk factors. The results are encouraging for the prospect of developing interventions to promote functional health and for reducing public health expenditures for physical disability in later life

Diagnostische delay bij longembolie

OBJECTIVE: To quantify the different stages of diagnostic delay of pulmonary embolism (PE) in patients and to identify other clinical factors associated with this delay. DESIGN: Case series. METHOD: Medical records were reviewed for all patients diagnosed with PE in the period 1 January 2008 and 31 December 2009 in Isala Hospital in Zwolle (the Netherlands), and data was collated for: the dates of symptom onset, presentation to a GP, referral to secondary care, and diagnosis respectively. The relationship between diagnostic delay and other clinical parameters such as gender, age, risk factors, symptoms and co-morbidities was tested using multivariate logistic regression analysis. RESULTS: For the 261 patients included in the analysis, the average total delay was 8.6 days. Patient delay (4.2 days average) and delay in primary care (3.9 days) were the major contributors to this delay. Chest pain and symptoms of deep venous thrombosis were associated with an early diagnosis. Patient delay was shorter in patients with chest pain and longer in patients with dyspnoea. In primary care, chest pain and rales were associated with an early referral, whereas the presence of co-morbidity led to a delayed referral. Delay in secondary care was shorter when the patient presented with dyspnoea. CONCLUSION: The diagnostic delay of PE is substantial, especially patient delay and delays originating in primary care. Further research is needed to identify clinical factors that raise suspicion of PE in primary care, to aid the development of improved diagnostic models

Diagnostic delay of pulmonary embolism in primary and secondary care : a retrospective cohort study

BACKGROUND: Delayed diagnosis of pulmonary embolism (PE) is common because symptoms can be non-specific. The few studies that have investigated diagnostic delay have not taken into account the role of primary care physicians in the diagnostic process. AIM: To document and quantify the stages of diagnostic delay of PE and to identify clinical factors associated with this delay. DESIGN AND SETTING: A retrospective cohort study conducted in Zwolle and its surroundings in the Netherlands. METHOD: Primary and secondary care records of all patients diagnosed with PE between January 2008 and December 2009 were reviewed for dates of symptom onset, date of presentation and diagnosis, and for clinical findings. Relationships between delay and clinical parameters were tested using multivariate regression analysis. RESULTS: The 261 patients enrolled in the study had an average total delay of 8.6 days. Patient delay (4.2 days average) and delay in primary care (3.9 days) were the major contributors to this delay. Chest pain (odds ratio [OR] 0.51, 95% confidence interval [CI] = 0.28 to 0.92, P = 0.03) and symptoms of deep venous thrombosis (calf pain) (OR 0.49, 95% CI = 0.24 to 0.98, P = 0.05) were associated with an early diagnosis. Patient delay was shorter in patients with chest pain (OR 0.49, 95% CI = 0.25 to 0.95, P = 0.03) and longer in patients with dyspnoea (OR 2.95, 95% CI = 0.99 to 8.85, P = 0.05). In primary care, chest pain (OR 0.37, 95% CI = 0.17 to 0.84, P = 0.02) and rales (OR 0.22, 95% CI = 0.06 to 0.83, P = 0.03) were associated with an early referral, whereas comorbidity led to a delayed referral. CONCLUSION: This study shows that the diagnostic delay of PE is substantial, especially patient delay and delay in primary care. There is room to reduce this delay by increasing the awareness of both patients and GPs. Further research is needed on clinical factors that raise suspicion of PE in primary care

Cognitive Functioning in Midlife and Old Age: Combined Effects of Psychosocial and Behavioral Factors

This study examined the joint protective contribution of psychosocial and behavioral factors to cognitive functioning and 10-year change, beyond the influence of sociodemographic factors, physical risk factors, health status, and engagement in cognitive activities. Participants were from the National Study of Midlife in the United States (MIDUS), ages 32-84 at Time 2, and a subsample, the Boston Longitudinal Study (BOLOS), ages 34-84 at Time 2. We computed a composite protective measure including control beliefs, quality of social support, and physical exercise variables at two occasions, 9-10 years apart. Cognition was assessed at Time 2 in MIDUS and at both occasions in BOLOS. Multiple regressions were used for analysis. In MIDUS, the more of the protective factors, the better the cognitive performance, and the protective composite moderated education differences in memory. In BOLOS, the Time 1 composite predicted change in reasoning abilities, with a greater protective effect for those with lower education. A combination of modifiable psychosocial and behavioral factors has both concurrent and long-term protective effects on cognition in adulthood. The results are promising in that educational disparities in memory and reasoning were reduced, suggesting possible interventions to protect against cognitive declines