Nonaneurysmal convexity subarachnoid hemorrhage.

BACKGROUND: Catheter angiography is performed to exclude aneurysm as the cause of subarachnoid hemorrhage (SAH). Certain categories of SAH however are for the most part nonaneurysmal and the risk of catheter angiography not justified. Primary convexity SAH may be nonaneurysmal and adequately investigated noninvasively. OBJECTIVE: Determine if primary convexity SAH is nonaneurysmal in origin. METHOD: Five new cases with primary convexity SAH and seven from the literature are reviewed for etiology, diagnostic studies, and outcome. RESULTS: Diagnostic investigations included catheter angiography in 6 patients, MR in 11 patients, computed tomography (CT) in 10 patients, magnetic resonance angiography/magnetic resonance venography in 7 patients, CT angiography in 1 patient, and outcome of the 12 patients was benign without subsequent hemorrhage. CONCLUSION: No case of primary convexity SAH was caused by aneurysm and outcome was benign in all patients, suggesting a noninvasive evaluation is adequate to investigate this condition.

D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review.

BACKGROUND: Despite extensive literature, the diagnostic role of d-dimer for deep venous thrombosis (DVT) or pulmonary embolism (PE) remains unclear, reflecting multiple d-dimer assays and concerns about differing sensitivities and variability. PURPOSE: To systematically review trials that assessed sensitivity, specificity, likelihood ratios, and variability among d-dimer assays. DATA SOURCES: Studies in all languages were identified by searching PubMed from 1983 to January 2003 and EMBASE from 1988 to January 2003. STUDY SELECTION: The researchers selected prospective studies that compared d-dimer with a reference standard. Studies of high methodologic quality were included in the primary analyses; sensitivity analysis included additional weaker studies. DATA EXTRACTION: Two authors collected data on study-level factors: d-dimer assay used, cutoff value, and whether patients had suspected DVT or PE. DATA SYNTHESIS: For DVT, the enzyme-linked immunosorbent assay (ELISA) and quantitative rapid ELISA dominate the rank order for these values: sensitivity, 0.96 (95% confidence limit [CL], 0.91 to 1.00), and negative likelihood ratio, 0.12 (CL, 0.04 to 0.33); and sensitivity, 0.96 (CL, 0.90 to 1.00), and negative likelihood ratio, 0.09 (CL, 0.02 to 0.41), respectively. For PE, the ELISA and quantitative rapid ELISA also dominate the rank order for these values: sensitivity, 0.95 (CL, 0.85 to 1.00), and negative likelihood ratio, 0.13 (CL, 0.03 to 0.58); and sensitivity, 0.95 (CL, 0.83 to 1.00), and negative likelihood ratio, 0.13 (CL, 0.02 to 0.84), respectively. The ELISA and quantitative rapid ELISA have negative likelihood ratios that yield a high certainty for excluding DVT or PE. The positive likelihood values, which are in the general range of 1.5 to 2.5, do not greatly increase the certainty of diagnosis. Sensitivity analyses do not affect these findings. LIMITATIONS: Although many studies evaluated multiple d-dimer assays, findings are based largely on indirect comparisons of test performance characteristics across studies. CONCLUSION: The ELISAs in general dominate the comparative ranking among the d-dimer assays for sensitivity and negative likelihood ratio. For excluding PE or DVT, a negative result on quantitative rapid ELISA is as diagnostically useful as a normal lung scan or negative duplex ultrasonography finding.

Venous thromboembolic disease: comparison of the diagnostic process in blacks and whites.

BACKGROUND: There has been concern that a disproportionate use of some health services exists among races. Whether this applies to patients with pulmonary embolism (PE) or deep venous thrombosis (DVT) has not been determined. OBJECTIVE: To assess if there is a racial disparity in the application of diagnostic tests for PE or DVT, or in reaching a diagnosis or using medical facilities. DESIGN: A study of cross-sectional samples of hospitalizations during 21 years using data from the National Hospital Discharge Survey. SETTING: Noninstitutional hospitals in 50 states and the District of Columbia from January 1, 1979, through December 31, 1999. PATIENTS: The National Hospital Discharge Survey abstracts demographic and medical information from the medical records of inpatients. For 1979 through 1999, the number of patients sampled ranged annually from 181 000 to 307 000. Measurements The number of sampled patients with DVT and with PE and the number of diagnostic tests performed were determined from the International Classification of Diseases, Ninth Revision, Clinical Modification codes at discharge. A multistage estimation procedure gave an estimate of values for the entire United States. RESULTS: The age-adjusted rates of diagnosis of PE and of DVT per 100 000 population were not lower in blacks than in whites. Rates of use of radioisotopic lung scans, venous ultrasonography of the lower extremities, and contrast venography were comparable between races. The durations of hospitalization for patients with a primary discharge diagnosis of PE and of DVT were also comparable. CONCLUSIONS: There is nothing to suggest that diagnostic tests are being withheld, and there is no evidence of a failure to reach a diagnosis in blacks with thromboembolic disease.

Venous thromboembolic disease: comparison of the diagnostic process in men and women.

BACKGROUND: There has been concern that women may be limited to fewer major diagnostic tests than men. Whether this applies to patients with pulmonary embolism (PE) or deep venous thrombosis (DVT) has not been determined. OBJECTIVE: To assess whether there is a sex disparity in the application of diagnostic tests for PE or DVT, in reaching a diagnosis, or in using medical facilities. DESIGN: A study of cross-sectional samples of hospitalizations from 21 separate years using data from the National Hospital Discharge Survey. SETTING: Noninstitutional hospitals in the 50 states and the District of Columbia from 1979 through 1999. PATIENTS: The National Hospital Discharge Survey abstracts demographic and medical information from the medical records of inpatients. For 1979 through 1999, the number of patients sampled ranged from 181000 to 307000.Measurements The number of sampled patients with DVT and with PE and the number of diagnostic tests performed were determined from the International Classification of Diseases, Ninth Revision, Clinical Modification codes at discharge. A multistage estimation procedure gave an estimation of values for the entire United States. RESULTS: Age-adjusted rates of the diagnosis of PE per 100000 population and of DVT per 100000 population were not lower in women. Rates of the use of ventilation-perfusion lung scans, venous ultrasonography of the lower extremities, and contrast venography were not lower in women. Durations of hospitalization for PE or DVT were comparable in men and women. CONCLUSION: Data from the National Hospital Discharge Survey do not support a sex bias in the diagnosis of PE or DVT, the use of diagnostic tests, or the duration of hospitalization for PE or DVT.

Upper extremity deep venous thrombosis.

PURPOSE: To determine the prevalence of symptomatic upper extremity deep venous thrombosis (DVT) and its association with symptomatic acute pulmonary embolism (PE) in a community teaching hospital. METHODS: The prevalence of symptomatic upper extremity DVT was evaluated retrospectively at a community teaching hospital during the 2-year period between July 1, 1998, and June 30, 2000. Patients were identified by International Classification of Disease, ninth revision, clinical modification, discharge codes and a review of the records of all compression Doppler ultrasonograms, venograms of the upper extremities, and magnetic resonance angiograms of the upper extremities. RESULTS: Symptomatic upper extremity DVT was diagnosed in 65 of 44,136 patients of all ages (0.15%) [or 64 of 34,567 adult patients >or= 20 years of age; 0.19%]. In seven patients, the upper extremity DVT was shown by venography to extend proximally to the brachiocephalic vein. Among these, the DVT extended to the superior vena cava in two. All of the patients received anticoagulant therapy for upper extremity DVT. No patients developed symptomatic PE. Central lines at the site of the upper extremity DVT were inserted in 39 of 65 patients (60%). Cancer was diagnosed in 30 of 65 patients (46%), 23 cancer patients also had central lines, and 19 patients (29%) had upper extremity DVT with no apparent cause. All patients had swelling of the upper extremities. Erythema over the affected site was present in four patients (6%). Pain was present in 26 patients (40%), although some discomfort due to swelling was present in all patients. CONCLUSION: Symptomatic upper extremity DVT is not uncommon in hospitalized patients. Symptomatic PE resulting from upper extremity DVT was not observed in these patients, all of whom were treated with anticoagulants.

Tracking the uptake of evidence: two decades of hospital practice trends for diagnosing deep vein thrombosis and pulmonary embolism.

BACKGROUND: Advances in clinical research methods have led to prospective randomized controlled (level 1) clinical studies evaluating diagnostic modalities resulting in a paradigm shift in the literature for diagnosing deep vein thrombosis (DVT) and pulmonary embolism (PE). To assess whether these advances correlate with clinical practice, we analyzed 21-year trends in diagnostic testing for patients with venous thromboembolism. METHODS: We used discharge data from the National Hospital Discharge Survey (1979-1999) to determine DVT and PE cases annually. Procedure fields were screened to determine patients who had DVT or PE or who underwent venography, arteriography of the pulmonary arteries, pulmonary scintigraphy, or DVT ultrasonic scanning. Searching EMBASE, MEDLINE, and the American Thoracic Society guidelines, a literature-based time line of level 1 studies was derived and juxtaposed against trends and procedure use. RESULTS: Improved diagnostic tests resulted in diagnostic changes in patients with suspected venous thromboembolism. These observed changes correlated over time in subsequent years with level 1 studies. Diagnostic DVT approaches showed an initial marked increased use of venography followed by a rapid decline that coincided with increased use of Doppler ultrasonography. Diagnostic approaches to PE were characterized by initial marked increases in lung scanning followed by a rapid decline as use of ultrasonography considerably increased and pulmonary angiography modestly increased. CONCLUSIONS: Diagnostic approaches to DVT and PE have changed markedly during the past 2 decades, in temporal harmony with the evolving literature. Change in clinical practice occurs over years, and long-term follow-up is required to capture this change.

Thromboembolic disease involving the superior vena cava and brachiocephalic veins.

PURPOSE: To evaluate the frequency of diagnosis and the characteristics of brachiocephalic vein and superior vena cava (SVC) thromboembolic disease. BACKGROUND: Thromboembolic disease of the brachiocephalic veins or SVC rarely has been reported. In view of the frequent use of central venous access lines, it would seem that the percentage of hospitalized patients with thromboembolic disease of the brachiocephalic veins or SVC should be higher than is generally recognized. METHODS: A retrospective search for thromboembolic disease involving the brachiocephalic veins and SVC was made of patients who were hospitalized over a 2-year period. RESULTS: Thromboembolic disease of the brachiocephalic veins or SVC was diagnosed in 23 of 34,567 hospitalized adults (0.06%) who were > or = 20 years old. Two of 23 patients (8.7%) had pulmonary embolism. Cancer was present in 17 of 23 patients (74%), and 15 of 23 patients (65%) had central venous access lines. Edema of the arm, face, or neck was present in 21 of 23 patients (91%). Pain or discomfort was present 15 of 23 patients (65%). CONCLUSION: Isolated brachiocephalic vein and SVC thrombosis occur in a sufficient number of hospitalized patients to merit consideration of the diagnosis in patients who have cancer, central venous access lines, or both. The signs and symptoms of brachiocephalic vein thrombosis have features in common with SVC syndrome as well as with upper extremity deep venous thrombosis. In a patient with appropriate clinical findings, venography or other imaging may be indicated.

Deep venous thrombosis in a general hospital.

PURPOSE: To determine the prevalence of proximal deep venous thrombosis (DVT) in a general hospital. BACKGROUND: In spite of the importance of proximal DVT, its prevalence in hospitalized patients has been only sparsely studied. METHODS: Patients hospitalized with DVT between July 1998 and June 2000 were identified by a computer search of discharge diagnoses. The discharge diagnosis was confirmed by a review of the records for positive findings on compression ultrasound or venogram of the lower extremities. In addition, records of all compression ultrasound examinations and venograms during that period were examined. RESULTS: The prevalence of proximal DVT in adults > or = 20 years old was 271 of 34,567 patients (0.78%). DVT was associated with pulmonary embolism in 57 of 271 patients (21.0%). The prevalence of DVT in adult men was 117 of 13,722 patients (0.85%), and in adult women was 154 of 20,845 patients (0.74%) [not significant]. The prevalence of DVT among men aged 20 to 49 years was higher than in women the same age: 19 of 3,982 patients (0.48%) vs 22 of 9,442 patients (0.23%), respectively (p < 0.02). The prevalence of DVT, however, was comparable among men and women > or = 50 years old. The prevalence of DVT was also comparable in black adults (30 of 4,344 patients; 0.69%) and in white adults (240 of 28,615 patients; 0.84%) [not significant]. CONCLUSION: Proximal DVT continues to be a frequent illness among hospitalized patients.

Estimated incidence of acute pulmonary embolism in a community/teaching general hospital.

PURPOSE: This study attempts to determine the incidence of established acute pulmonary embolism (PE) in a community/teaching general hospital. BACKGROUND: The reported incidence of objectively diagnosed acute PE among hospitalized adults in a large urban hospital or major university hospital ranges from 0.27 to 0.40%. Whether the incidence of PE in other categories of hospitals fits within this narrow range is unknown. METHODS: Patients with acute PE diagnosed by ventilation/perfusion lung scan, pulmonary angiography, compression ultrasound in a patient with suspected PE, autopsy, or (by coincidence) lung biopsy were identified among patients hospitalized during a 2-year period from 1998 to 2000. The incidence of PE was also determined according to age, sex, and race. RESULTS: Among adult patients (> or = 20 years old), the incidence of established acute PE was 95 of 34,567 patients (0.27%; 95% confidence interval [CI], 0.22 to 0.34%). No PE was diagnosed in patients < 20 years old. The incidence of PE in men was 36 of 13,722 patients (0.26%; 95% CI, 0.18 to 0.36%); in women, it was 59 of 20,845 patients (0.2%; 95% CI, 0.22 to 0.36%; not significant [NS]). The incidence in African-Americans adults was 10 of 4,344 patients (0.23%; 95% CI, 0.11 to 0.42%); in white adults, it was 84 of 28,615 patients (0.29%; 95% CI, 0.23 to 0.36%; NS). CONCLUSION: The incidence of PE in a community/teaching general hospital was comparable to the incidence in a large urban-care center and in a major university hospital.