临床量表对肺栓塞诊断价值的研究

Objective To assess diagnostic value of Wells and Geneva seales in patients with suspected pulmonary embolism(PE).Methods Clinical data of 958 consecutive cases of suspected PE admitted to Shanghai Pulmonary Hospital form January 1,1995 to January 1,2009,were analyzed retrospectively,and all patients were assessed with Wells and Geneva scales,respectively for likelihood of PE,as compared to those diagnosed by lung imaging Results Three hundred and forty-seven patients with PE were diagnosed with lung imaging as gold standard,sensitivity,specificity,and positive and negative predictive values for Wells scale and Geneva scale in diagnosis for PE were 82.4%,58.1%,52.8%and 85.3%.and 88.8%,55.3%,53.1%and 89.7%,respectively,with positive and negative likelihood ratios.Youden index and crude agreement of 1.97,0.30,0.41 and 0.21,and 1.99,0.20,0.44 and 0.25.respectively.Area under the receiver operating characteristic(ROC) curve of Geneva scale(0.79)was significantly more than that of Wells scale(0.73)(Z=2.25,P＜0.05).As compared to Wells scale,sensitivity and specificity for Geneva scale in diagnosis for PE was significantly higher(χ2=7.12 and 6.84,respectively,P＜0.05).Conclusions Although there is a considerable gap in accuracy between clinical scales and lung imaging in diagnosis for PE.both Wells and Geneva scales can be used in clinical screening for PE to save unnecessary cost.however,Geneva scale is more practical and accurate than Wells scale,worthwhile to be popularized clinically.     

Endobronchial ultrasound-guided transbronchial needle aspiration of undiagnosed mediastinal lymphadenopathy

Background Endobronchial ultrasound-guided transbronchial needle aspiration （EBUS-TBNA） can sample the enlarged mediastinal lymph nodes which are unreachable by conventional bronchoscopy.It is a relatively simple and safe method to see beyond the bronchial tree.We describe and discuss its initial application and our experience.Methods From July 2009 to December 2009, 52 patients with undiagnosed enlarged mediastinal lymph nodes were accessed with EBUS-TBNA in the People＇s Liberation Army General Hospital.Conventional bronchoscopy was performed before EBUS-TBNA, and patients with endobronchial lesions were excluded from this study.Smears fixed in 95% alcohol and histological specimens fixed in formalin were sent to Department of Pathology.Results EBUS-TBNA was diagnostic in 33 （63%） patients, with diagnosis of lung cancer in 23 patients （14 patients of small cell lung cancer, eight patients with adenocarcinoma, and one patient of squamous carcinoma）.Four patients, who had negative EBUS-TBNA results, were later diagnosed with malignancy at thoracotomy.One patient with negative EBUS-TBNA results died of cancer cachexia.The sensitivity, specificity, and positive and negative predictive value of EBUS-TBNA for the diagnosis of neoplastic disease were 85%, 100%, 100%, and 50% respectively.Among the 16sarcoidosis patients, who were diagnosed by a combination of the clinical and radiological information as well as pathological results obtained by EBUS-TBNA, nine of them had granulomas and benign lymphoid cells detected by EBUS-TBNA.The sensitivity, specificity, and positive and negative predictive value of EBUS-TBNA for the diagnosis of sarcoidosis were 56%, 100%, 100%, and 13%, respectively.Five patients with no definite diagnosis from EBUS-TNBA examination are under close follow-up.Conclusions EBUS-TBNA can provide a safe and effective method to sample mediastinal leisions suspected of malignancy.It also adds pathological information needed to make the diagnosis of sarcoidosis.     

The value of 18-FDG-PET for diagnosing and evaluating lymph node metastasis in primary breast cancer

Objective： To analyze the result of 18F-2-deoxy-2-fluoro-D-glucose-positron emission tomography （FDG-PET） in suspicious primary breast cancer patients and to evaluate its value for the surgery therapy. Methods： Total 36 patients suspected of breast neoplasm were enrolled into the research. The result was compared with the pathology result. The rate of missed diagnosis, the rate of misdiagnosis, the sensitivity and specificity were calculated and analyzed. Results ：Compared with the pathology results, the misdiagnosis rate, the rate of missed diagnosis, the sensitivity and specificity of FDG-PET for breast cancer were 0%, 36.36%, 63.63% and 100%, respectively. To those who had a neoplasm no more than 2 cm in diameter, the rate of missed diagnosis was as high as 41.67%. To 33 breast cancer patients, the misdiagnosis rate, the rate of missed diagnosis, the sensitivity and specificity for lymph node metastasis were 18.75%, 41.18%, 58.82% and 81.25%, respectively. Conclusion：FDG-PET has a perfect specificity and a considerable sensitivity to the primary breast neoplasm and similar to the lymph node metastasis diagnosis. It is an ideal choice for those patients with suspected breast cancer but reluctantly to receive a vulnerarious examination.     

Clinical features and diagnosis for Chinese cases with malignant hyperthermia: a case cluster from 2005 to 2007

Background Malignant hyperthermia （MH）, manifesting as MH crisis during and/or after general anesthesia, is a potentially fatal disorder in response to volatile anesthetics and depolarizing muscle relaxants. Though typical features of MH episode can provide clues for clinical diagnosis, MH susceptibility is confirmed by in vitro caffeine-halothane contracture test （CHCT） in western countries. It is traditionally thought that MH has less incidence and fewer typical characteristics in Chinese population than their western counterparts because of the different genetic background. In this study, we investigated the clinical features of MH in Chinese cases and applied the clinical grading scale and CHCT for diagnosis of MH. Methods A cluster of three patients with MH, from January 2005 to December 2007, were included in the study. Common clinical presentations and the results of some lab examinations were reported in detail. The method of the clinical grading scale of diagnosis of MH was applied to estimate the qualitative likelihood of MH and predict MH susceptibility. Muscle fibers of femoral quadriceps of the patients were collected and CHCT was performed to confirm the diagnosis of MH. Results The clinical grading scales of diagnosis of the disease for these cases were all ranked grade D6, suggesting almost diagnosed ones. And the results of caffeine test were positive correspondingly, indicating that the patients should be diagnosed as MH susceptibility （MHS） according to diagnostic criteria of the North America MH group, which were already confirmed by clinical presentations and biochemical results. Conclusions These Chinese cases manifest as MH crisis. The clinical grading scale of diagnosis of MH may provide clues for clinical diagnosis. CHCT can also be used in confirming diagnosis of MH in Chinese cases though they have different genetic background from their western counterparts.     

Diagnostic value of endobronchial ultrasound-guided transbronchial needle aspiration in intrapulmonary lesions

Background Endobronchial ultrasound-guided transbronchial needle aspiration （EBUS-TBNA） is considered to have high value in the staging of mediastinal lymph nodes in lung cancer. The current study was conducted to investigate the diagnostic value of EBUS-TBNA in intrapulmonary lesions located near the central airway. Methods From September 2009 to March 2013, 66 patients with pulmonary masses located close to the central airways suspected to be lung cancer were accessed by EBUS-TBNA. Conventional bronchoscopic biopsy before EBUS-TBNA was nondiagnostic in all cases. If EBUS-TBNA did not result in a formal pathological diagnosis of malignancy, patients were subsequently referred for a surgical procedure. ResuLts Among the 66 cases, 59 were confirmed as pulmonary malignancies by EBUS-TBNA, of which 48 cases were non-small cell lung cancer, nine were small cell lung cancer, and two were metastatic lung tumors. No evidence of malignancy was found by biopsy and histopathological examination in the other seven cases. Thoracoscopy or thoracotomy was subsequently undergone for them. Postoperative pathological examinations confirmed three cases of squamous cell carcinoma of the lung, one case of lymphoma, two cases of sclerosing hemangioma, and one case of pulmonary tuberculoma. The definitive diagnosis rate of EBUS-TBNA for intrapulmonary lesions near the central airway was 89.4%. The sensitivity, specificity, and accuracy of EBUS-TBNA in distinguishing benign from malignant intrapulmonary lesions were 93.7%, 100.0%, and 93.9%, respectively. The positive and negative predictive values were 100.0% and 42.9%, respectively. The EBUS-TBNA procedures were well-tolerated by all patients. No associated complications were observed. Conclusions For intrapulmonary lesions near the central airway highly suspected of cancer, EBUS-TBNA has satisfactory diagnostic value. However, the negative predictive value of this technique is low, so negative results obtained by EBUSTBNA should be confirmed by other methods.     

Comparison of four clinical scores for the predicting lower limb deep venous thrombosis in Chinese patients

Objective:To evaluate Wells,Kahn,St.Andréand Constans scores for the prediction of deep venous thrombosis in Chinese patients. Methods:One hundred and seventy-two patients,prospectively,blinded referred for evaluation with four clinical-score systems for suspected deep venous thrombosis,were examined by ultrasonography. Sensitivity,specificity,positive predictive value,nega-tive predictive value and receiver operation curves were calculated for four clinical scores. The difference between areas of the ROC curve for each of the scores was compared with others and reference line. Results:Forty-six of 172 patients had deep venous throm-bosis proven by sonography. The sensitivity,specificity,positive predictive value and negative predictive value for Wells score was 91.3%,57.1%,43.8% and 94.7%,respectively,for Kahn score; 65.2%,71.4%,45.5% and 84.9%,respectively,for St.Andréscore; 63%,38.9%,27.4% and 74.2% respectively,for Constans score; 95.7%,34.9%,34.9% and 95.7% respectively. Area under ROV curve of Constans score was 0.814,which was similar to that of Wells score,then followed by Kahn score and that of St.Andréscore was no difference with the reference line. Conclusion:Based on the results of our study,the sensitivity,negative prediction value and area under ROC curve are larger for Constans score and Wells score in Chinese hospitalized patients than that of Kahn score or St.Andréscore. Considering the aim of the clinical assessment,Constans score and Wells score are more efficient for Chinese hospitalized patients.     

Normal blood D-dimer concentrations： do they exclude pulmonary embolism？

Background Although pulmonary embolism （PE） with normal blood D-dimer （DD） concentrations is considered rare,in practice the incidence may be greater than is generally believed.Overlooking PE is potentially dangerous.The aim of this study was to explore the incidence and clinical features of PE with normal DD concentrations.Methods We retrospectively analyzed the records of 29 patients with PE and normal DD concentrations from the past seven years.We here compare relevant clinical characteristics of these patients with those of patients with PE and abnormal DD concentrations.We evaluated the probabilities of differences by computing pretest probability scores （Wells score and revised Geneva score）.Results The frequency of normal DD concentrations in patients with PE was 4％.Previous episode（s） of PE were more common in patients with normal DD concentrations than in those with abnormal DD concentrations （P=0.001）.Fever,tachycardia,and tachypnea occurred less frequently in the former group （P＜0.05） and time between onset of symptoms and DD testing was longer （P=0.001）.The diagnosis of PE was delayed in 22 of the 29 cases.Nineteen and seven cases with normal DD concentrations were classified according to pretest scores as intermediate and low risk,respectively.Conclusions PE with normal DD concentrations is uncommon.Although most diagnoses of PE are ruled out by normal DD values,a small number of cases with PE are missed.A combination of pretest probability score and normal DD concentration increases the probability of making the correct diagnosis,but cannot completely exclude patients with suspected PE.When the clinical manifestations cannot be otherwise explained,clinicians should be alert to the possibility of PE with normal DD concentrations in patients with previous episode（s） of PE or a long interval between onset of symptoms and DD testing.     

Pulmonary embolism in adolescents

Background  Pulmonary embolism (PE) is rare and seldom considered in adolescent patients; however it occurs with a greater frequency than is generally recognized, and it is a potentially fatal condition. The aim of the current study was to understand its epidemiology, clinical features and the cause of delay of its diagnosis in adolescents.

Methods  A retrospective analysis of nine adolescents with acute PE admitted to the Peking University Third Hospital over the past 16-year period was performed. The epidemiology, clinical features and risk factors of the adolescents were described and compared with those of adults and elderly patients. The time to diagnosis and misdiagnosed diseases were analyzed. Pretest probability of PE was assessed retrospectively by the Wells score and revised Geneva score.

Results  The incidence of PE was 43.6 per 100 000 hospitalized adolescents in our hospital. The incidence of PE in adolescents was much lower than that in adults and PE is diagnosed in about 1/50 of elderly people. The clinical features in adolescents were similar to those in adults. But fever and chest pain were more common in adolescents (P <0.05). The major risk factors included surgery, systemic lupus erythematosus (SLE), thrombocytopenia, long-term oral glucocorticoids and trauma. The mean diagnostic time was (7.8±8.4) days. Six cases had a delayed diagnosis. The mean delay time from symptom onset to diagnosis was (11.0±8.8) days. The time of presentation to diagnosis in patients initially admitted to the emergency department was less than one day, and was much shorter than the time in outpatients, (9.4±7.5) days. Most of the patients were initially misdiagnosed with a respiratory tract infection. Most patients’ values of Wells score or revised Geneva score were in the moderate or high clinical probability categories; 88% by Well score vs. 100% by revised Geneva score.

Conclusions  PE was seldom considered in the adolescent patients by physicians, especially outpatient physicians, so the diagnosis was often delayed. If adolescent patients complain of dyspnea or chest pain or syncope with/without fever, and they had risk factors such as surgery, thrombocytopenia and trauma, PE should be considered and included in the differential diagnosis.

     

DIAGNOSTIC VALUE OF WHOLE BODY DIFFUSION WEIGHTED IMAGING FOR SCREENING PRIMARY TUMORS OF PATIENTS WITH METASTASES

Objective To evaluate the values of whole body diffusion weighted imaging （DWI） in screenmg pnmary unknown tumor in patients with metastases.
Methods Totally, 34 patients with metastases of primary unknown tumors were scanned with whole body DWI, and conventional magnetic resonance （MR） imaging was performed if suspected lesions were detected. All the metastases including 27 cases of osseous metastases, 2 brain metastases, 2 liver metastases, 1 pulmonary multiple metastasis, 1 neck metastasis and 1 malignant ascites, were diagnosed by computed tomography, single photon emission computed tomography, or MR imaging. For the proven primary tumors diagnosed by biopsy or pathology of surgical specimens, apparent diffusion coefficient （ADC） values of the primary and metastatic lesions were measured respectively. The sensitivity and specificity of this technique for screening primary tumors were cvaluated.
Results We found 24 cases with suspected primary lesions, in which 23 lesions were proved to be primary tumors, and 1 was proved to be benign lesion. And no definite primary lesion was found in 10 cases on whole body DWI, but in which 1 case was diagnosed with primary tumor by biopsy later, and the other 9 cases remained unknown within follow-up of over halfa year. The difference was not significant in ADC values between primary and metastatic lesions （P〉0.05）. The sensitivity and specificity of whole body DWI for searching primary tumors was 95.8% and 90.0%, respectively.
Conclusion Combined with conventional MR scanning, whole body DWI can help to search primary lesions of patients with metastases.     

The value of CT pulmonary angiography to the diagnosis of right ventricular dysfunction due to acute pulmonary embolism： compared with ultrasonographic cardiography

Objective:To analyze the value of CT pulmonary angiography(CTPA) in assessing right ventricular dysfunction(RVD) after acute pulmonary embolism. Methods:Thirty-six patients with CTPA-confirmed PE who underwent ultrasonic cardiography(UCG) within the ensuing 24 hours were retrospectively reviewed. According to the severity of the disease,the patients were divided into the massive PE group(24 cases) and non-massive PE group(12 cases) respectively. CT scans were analyzed for findings suggestive of RVD. Scans were considered positive for RVD if the right ventricle was dilated(RVd/LVd>1) or if the interventricular septum was straightened or deviated towards the left ventricle. Results were then compared with the results of UCG to estimate the value of CTPA in detecting RVD associated with PE. Results:In all cases,compared with UCG,the diagnostic sensitivity,specificity,positive likelihood ratio,negative likelihood ratio,positive predictive value,and negative predictive value of CTPA was 84.61%,78.26%,3.892,0.197,68.75% and 90% respectively. Kappa value was 0.60,which suggested moderate agreement between CTPA and UCG in the whole level. In the massive PE group,the diagnostic sensitivity,specificity,positive likelihood ratio,negative likelihood ratio,positive predictive value,negative predictive value of CTPA was 84.61%,72.73%,3.103,0.212,78.57% and 80% respectively. Kappa value was 0.58,which suggested moderate agreement between CTPA and UCG in the massive PE group. In the non-massive PE group,the diagnostic specificity of CTPA was 83.33%. By statistics,the value of RVd/LVd had significant difference between the massive PE and the non-massive PE group. Conclusion:CTPA can reliably detect RVD through the evaluation of cardiac morphology. However,this result requires confirmation using a larger prospective cohort study.