Splendors and miseries of expired CO2 measurement in the suspicion of pulmonary embolism

Capnography has been studied for decades as a potential diagnostic tool for suspected pulmonary embolism. Despite technological refinements and its combination with other non-invasive instruments, no evidence to date allows recommending the use of expired carbon dioxide measurement as a rule-out test for pulmonary embolism without additional radiological testing. Further investigations are, however, still warranted

Validation of a model to predict adverse outcomes in patients with pulmonary embolism

Aims To validate a model for quantifying the prognosis of patients with pulmonary embolism (PE). The model was previously derived from 10 534 US patients. Methods and results We validated the model in 367 patients prospectively diagnosed with PE at 117 European emergency departments. We used baseline data for the model's 11 prognostic variables to stratify patients into five risk classes (I-V). We compared 90-day mortality within each risk class and the area under the receiver operating characteristic curve between the validation and the original derivation samples. We also assessed the rate of recurrent venous thrombo-embolism and major bleeding within each risk class. Mortality was 0% in Risk Class I, 1.0% in Class II, 3.1% in Class III, 10.4% in Class IV, and 24.4% in Class V and did not differ between the validation and the original derivation samples. The area under the curve was larger in the validation sample (0.87 vs. 0.78, P=0.01). No patients in Classes I and II developed recurrent thrombo-embolism or major bleeding. Conclusion The model accurately stratifies patients with PE into categories of increasing risk of mortality and other relevant complications. Patients in Risk Classes I and II are at low risk of adverse outcomes and are potential candidates for outpatient treatmen

Multicenter Evaluation of a 0-Hour/1-Hour Algorithm in the Diagnosis of Myocardial Infarction With High-Sensitivity Cardiac Troponin T

Study objectiveWe aim to prospectively validate the diagnostic accuracy of the recently developed 0-h/1-h algorithm, using high-sensitivity cardiac troponin T (hs-cTnT) for the early rule-out and rule-in of acute myocardial infarction.MethodsWe enrolled patients presenting with suspected acute myocardial infarction and recent (<6 hours) onset of symptoms to the emergency department in a global multicenter diagnostic study. Hs-cTnT (Roche Diagnostics) and sensitive cardiac troponin I (Siemens Healthcare) were measured at presentation and after 1 hour, 2 hours, and 4 to 14 hours in a central laboratory. Patient triage according to the predefined hs-cTnT 0-hour/1-hour algorithm (hs-cTnT below 12 ng/L and Δ1 hour below 3 ng/L to rule out; hs-cTnT at least 52 ng/L or Δ1 hour at least 5 ng/L to rule in; remaining patients to the “observational zone”) was compared against a centrally adjudicated final diagnosis by 2 independent cardiologists (reference standard). The final diagnosis was based on all available information, including coronary angiography and echocardiography results, follow-up data, and serial measurements of sensitive cardiac troponin I, whereas adjudicators remained blinded to hs-cTnT.ResultsAmong 1,282 patients enrolled, acute myocardial infarction was the final diagnosis for 213 (16.6%) patients. Applying the hs-cTnT 0-hour/1-hour algorithm, 813 (63.4%) patients were classified as rule out, 184 (14.4%) were classified as rule in, and 285 (22.2%) were triaged to the observational zone. This resulted in a negative predictive value and sensitivity for acute myocardial infarction of 99.1% (95% confidence interval [CI] 98.2% to 99.7%) and 96.7% (95% CI 93.4% to 98.7%) in the rule-out zone (7 patients with false-negative results), a positive predictive value and specificity for acute myocardial infarction of 77.2% (95% CI 70.4% to 83.0%) and 96.1% (95% CI 94.7% to 97.2%) in the rule-in zone, and a prevalence of acute myocardial infarction of 22.5% in the observational zone.ConclusionThe hs-cTnT 0-hour/1-hour algorithm performs well for early rule-out and rule-in of acute myocardial infarction

Prediagnostic Serum Vitamin D Levels and the Risk of Crohn’s Disease and Ulcerative Colitis in European Populations: A Nested Case-Control Study

Background: A low vitamin D status has been put forward as a potential risk factor for the development of inflammatory bowel disease (IBD). This study investigated the association between prediagnostic circulating vitamin D concentrations and dietary intakes of vitamin D, and the risk of Crohn’s disease (CD) and ulcerative colitis (UC). Methods: Among 359,728 participants of the European Prospective Investigation into Cancer and Nutrition cohort, individuals who developed CD or UC after enrollment were identified. Each case was matched with2 controls by center, gender, age, date of recruitment, and follow-up time. At cohort entry, blood samples were collected and dietary vitamin D intakes were obtained from validated food frequency questionnaires. Serum 25-hydroxyvitamin D levels were measured using liquid chromatography-tandem mass spectrometry. Conditional logistic regression was performed to determine the odds of CD and UC. Results: Seventy-two participants developed CD and 169 participants developed UC after a median follow-up of 4.7 and 4.1 years, respectively. Compared with the lowest quartile, no associations with the 3 higher quartiles of vitamin D concentrations were observed for CD (p trend = 0.34) or UC (p trend = 0.66). Similarly, no associations were detected when serum vitamin D levels were analyzed as a continuous variable. Dietary vitamin D intakes were not associated with CD (p trend = 0.39) or UC (p trend = 0.83). Conclusions: Vitamin D status was not associated with the development of CD or UC. This does not suggest a major role for vitamin D deficiency in the etiology of IBD, although larger studies are needed to confirm these findings

Volumetric capnography in the diagnosis and the therapeutic monitoring of pulmonary embolism in the emergency department

CO2 and its influence on environmental and ecological processes focuses the attention of all current media. In the medical area, expired CO2 measurement with Capnography has gained acceptance for all patients needing clinical monitoring and supervision. But recent research works are showing the promises of CO2 as a diagnostic tool or therapeutic monitoring. In this case, measurement of expired CO2 in function of the expired volume, called Volumetric Capnography, has a theoretical better performance than the traditional time-based Capnography. When expired CO2 data are combined to arterial CO2 sampling, the clinician faces breath-by-breath curves, which give a bedside knowledge of the pulmonary ventilation and perfusion status of his patient. Pulmonary embolism is a particular application of Volumetric Capnography. This frequent and challenging disease is characterized by impaired relationships between the pulmonary ventilation and perfusion, going from deadspace to shunt. Volumetric Capnography deserves a careful attention in this area, since its combination with other clinical or biological signs could become part of a diagnostic procedure, either for the detection of the disease when capnographic parameters are clearly impaired, or for ruling out this diagnosis when Volumetric Capnography analysis is normal. In the same way, monitoring the efficacy of thrombolytic therapy when pulmonary embolism is massive is another particular interest for expired CO2 measurement. Physicians working in the Emergency Department demand performing devices for improving patient care. Such devices can be particularly adapted to daily practice if they can be used by the bedside, if they are non-invasive, safe, efficient, feasible, and applicable to non-intubated patients. Volumetric Capnography, which seems to answer those requirements, will certainly deserve growing attention and interest in the future as a direct application of pulmonary pathophysiology. Even if Volumetric Capnography is still at the frontier between clinical research and clinical practice, let us hope that the studies presented in this thesis will improve the clinical acceptance of this attractive technology.(MED 3) -- UCL, 200

To PERC or not to PERC?

Philosophy & Controversies - P&C Thrombosi

Don d'organes et de tissus: livre de poche. Réponses aux questions fréquemment posées

Ce livre veut être un guide pratique destiné à tous les médecins, aux infirmiers et paramédicaux concernés par les dons d'organe. Tous les aspects de transplantations d'organes s'y trouvent: l'identification du donneur d'organe potentiel, l'allocation des organes, les indications avant et les résultats de la transplantation, le don de tissus, la gestion du donneur, le don d'organe après la mort cérébrale ou l'arrêt circulatoire irréversible, les aspects juridiques et éthiques ainsi que l'approche et la prise en charge de la famille. Ce guide pratique contient des contributions de nombreux experts issus de plusieurs universités et hôpitaux de Belgique

DOCTEUR, JE SUIS ESSOUFFLÉ : LA PHYSIOLOGIE RESPIRATOIRE AU SERVICE DU MÉDECIN GÉNÉRALISTE

Cet article établit quelques-uns des liens fondamentaux entre la physiologie respiratoire de base et la pratique de la médecine clinique telle qu’elle se présente en consultation, quand un patient évoque des symptômes d’origine pulmonaire, ou quand ce patient cherche auprès de son médecin des explications au bon fonctionnement de ses poumons et de sa respiration