Doppler trans-thoracic echocardiography for detection of pulmonary hypertension in adults.

BACKGROUND: Pulmonary hypertension (PH) is an important cause of morbidity and mortality, which leads to a substantial loss of exercise capacity. PH ultimately leads to right ventricular overload and subsequent heart failure and early death. Although early detection and treatment of PH are recommended, due to the limited responsiveness to therapy at late disease stages, many patients are diagnosed at a later stage of the disease because symptoms and signs of PH are nonspecific at earlier stages. While direct pressure measurement with right-heart catheterisation is the clinical reference standard for PH, it is not routinely used due to its invasiveness and complications. Trans-thoracic Doppler echocardiography is less invasive, less expensive, and widely available compared to right-heart catheterisation; it is therefore recommended that echocardiography be used as an initial diagnosis method in guidelines. However, several studies have questioned the accuracy of noninvasively measured pulmonary artery pressure. There is substantial uncertainty about the diagnostic accuracy of echocardiography for the diagnosis of PH. OBJECTIVES: To determine the diagnostic accuracy of trans-thoracic Doppler echocardiography for detecting PH. SEARCH METHODS: We searched MEDLINE, Embase, Web of Science Core Collection, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform from database inception to August 2021, reference lists of articles, and contacted study authors. We applied no restrictions on language or type of publication. SELECTION CRITERIA: We included studies that evaluated the diagnostic accuracy of trans-thoracic Doppler echocardiography for detecting PH, where right-heart catheterisation was the reference standard. We excluded diagnostic case-control studies (two-gate design), studies where right-heart catheterisation was not the reference standard, and those in which the reference standard threshold differed from 25 mmHg. We also excluded studies that did not provide sufficient diagnostic test accuracy data (true-positive [TP], false-positive [FP], true-negative [TN], and false-negative [FN] values, based on the reference standard). We included studies that provided data from which we could extract TP, FP, TN, and FN values, based on the reference standard. Two authors independently screened and assessed the eligibility based on the titles and abstracts of records identified by the search. After the title and abstract screening, the full-text reports of all potentially eligible studies were obtained, and two authors independently assessed the eligibility of the full-text reports. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the risk of bias and extracted data from each of the included studies. We contacted the authors of the included studies to obtain missing data. We assessed the methodological quality of studies using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. We estimated a summary receiver operating characteristic (SROC) curve by fitting a hierarchical summary ROC (HSROC) non-linear mixed model. We explored sources of heterogeneity regarding types of PH, methods to estimate the right atrial pressure, and threshold of index test to diagnose PH. All analyses were performed using the Review Manager 5, SAS and STATA statistical software. MAIN RESULTS: We included 17 studies (comprising 3656 adult patients) assessing the diagnostic accuracy of Doppler trans-thoracic echocardiography for the diagnosis of PH. The included studies were heterogeneous in terms of patient distribution of age, sex, WHO classification, setting, country, positivity threshold, and year of publication. The prevalence of PH reported in the included studies varied widely (from 6% to 88%). The threshold of index test for PH diagnosis varied widely (from 30 mmHg to 47 mmHg) and was not always prespecified. No study was assigned low risk of bias or low concern in each QUADAS-2 domain assessed. Poor reporting, especially in the index test and reference standard domains, hampered conclusive judgement about the risk of bias. There was little consistency in the thresholds used in the included studies; therefore, common thresholds contained very sparse data, which prevented us from calculating summary points of accuracy estimates. With a fixed specificity of 86% (the median specificity), the estimated sensitivity derived from the median value of specificity using HSROC model was 87% (95% confidence interval [CI]: 78% to 96%). Using a prevalence of PH of 68%, which was the median among the included studies conducted mainly in tertiary hospitals, diagnosing a cohort of 1000 adult patients under suspicion of PH would result in 88 patients being undiagnosed with PH (false negatives) and 275 patients would avoid unnecessary referral for a right-heart catheterisation (true negatives). In addition, 592 of 1000 patients would receive an appropriate and timely referral for a right-heart catheterisation (true positives), while 45 patients would be wrongly considered to have PH (false positives). Conversely, when we assumed low prevalence of PH (10%), as in the case of preoperative examinations for liver transplantation, the number of false negatives and false positives would be 13 and 126, respectively. AUTHORS' CONCLUSIONS: Our evidence assessment of echocardiography for the diagnosis of PH in adult patients revealed several limitations. We were unable to determine the average sensitivity and specificity at any particular index test threshold and to explain the observed variability in results. The high heterogeneity of the collected data and the poor methodological quality would constrain the implementation of this result into clinical practice. Further studies relative to the accuracy of Doppler trans-thoracic echocardiography for the diagnosis of PH in adults, that apply a rigorous methodology for conducting diagnostic test accuracy studies, are needed.

Amlodipine-Induced Subacute Cutaneous Lupus Erythematosus Localized to Non-Sun-Exposed Areas.

The cutaneous manifestations of subacute cutaneous lupus erythematosus (SCLE), a subset of cutaneous lupus erythematosus, arise most often in sun-exposed areas. We report a case of SCLE with atypical distribution, following treatment with amlodipine. This highlighted a possible clue that can be used to clinically distinguish a drug-induced case from an idiopathic disorder. A 92-year-old Japanese woman presented with a 2-month history of progressive erythematous, papulosquamous rash, and annular plaques in non-sun-exposed sites with no systemic symptoms. Irbesartan/amlodipine besilate combination tablets were prescribed 8 months earlier for hypertension. The appearance of the skin eruptions, results of immunopathological findings, and temporal relationship between the rash and drugs were suggestive of a diagnosis of drug-induced SCLE, which was confirmed by the spontaneous resolution of these cutaneous eruptions within 4 weeks after cessation of amlodipine treatment. The evaluation of possible associations with medications should be performed in patients presenting with clinical features characterizing SCLE in atypical sites (non-sun-exposed areas).

Ulcerative Lupus Vulgaris on the Wrist.

We report a case of ulcerative lupus vulgaris (LV) in a unique site, which facilitated the detection of internal organ tuberculosis (TB). A 68-year-old Japanese man presented with a reddish ulcerated painless lesion on his right wrist that had initially appeared 4 weeks earlier as a nontender nodule. There was no recent history of fever, weight loss, or cough. The results of tissue culture, PCR, and contrast-enhanced chest computed tomography were consistent with the diagnosis of ulcerative LV with underlying pulmonary TB and tuberculous lymphadenitis. The patient was started on anti-TB therapy. After 1 month of therapy, epithelialization of the ulcer was noted.

Deterministic quantum teleportation of photonic quantum bits by a hybrid technique.

Quantum teleportation allows for the transfer of arbitrary unknown quantum states from a sender to a spatially distant receiver, provided that the two parties share an entangled state and can communicate classically. It is the essence of many sophisticated protocols for quantum communication and computation. Photons are an optimal choice for carrying information in the form of 'flying qubits', but the teleportation of photonic quantum bits (qubits) has been limited by experimental inefficiencies and restrictions. Main disadvantages include the fundamentally probabilistic nature of linear-optics Bell measurements, as well as the need either to destroy the teleported qubit or attenuate the input qubit when the detectors do not resolve photon numbers. Here we experimentally realize fully deterministic quantum teleportation of photonic qubits without post-selection. The key step is to make use of a hybrid technique involving continuous-variable teleportation of a discrete-variable, photonic qubit. When the receiver's feedforward gain is optimally tuned, the continuous-variable teleporter acts as a pure loss channel, and the input dual-rail-encoded qubit, based on a single photon, represents a quantum error detection code against photon loss and hence remains completely intact for most teleportation events. This allows for a faithful qubit transfer even with imperfect continuous-variable entangled states: for four qubits the overall transfer fidelities range from 0.79 to 0.82 and all of them exceed the classical limit of teleportation. Furthermore, even for a relatively low level of the entanglement, qubits are teleported much more efficiently than in previous experiments, albeit post-selectively (taking into account only the qubit subspaces), and with a fidelity comparable to the previously reported values.

Generating superposition of up-to three photons for continuous variable quantum information processing.

We develop an experimental scheme based on a continuous-wave (cw) laser for generating arbitrary superpositions of photon number states. In this experiment, we successfully generate superposition states of zero to three photons, namely advanced versions of superpositions of two and three coherent states. They are fully compatible with developed quantum teleportation and measurement-based quantum operations with cw lasers. Due to achieved high detection efficiency, we observe, without any loss correction, multiple areas of negativity of Wigner function, which confirm strongly nonclassical nature of the generated states.