T o o muc h me dic ine a nd ve no us thro mb o e mb o lism: Ho w - - PowerPoint PPT Presentation
T o o muc h me dic ine a nd ve no us thro mb o e mb o lism: Ho w c a n we ma ke thing s We ll a g a in? E mily G Mc Do na ld MD MSc ; Assista nt pro fe sso r o f me dic ine ; Mc Gill Unive rsity He a lth Ce ntre Ca na dia n So c ie
E mily G Mc Do na ld MD MSc ; Assista nt pro fe sso r o f me dic ine ; Mc Gill Unive rsity He a lth Ce ntre Ca na dia n So c ie ty o f Inte rna l Me dic ine ; No ve mb e r, 2017; T
pulmo na ry a ng io g ra m (a nd ve no us Do pple r)
E
E within yo ur pra c tic e
muc h me d ic ine ”
Re se a rc h a nd the Ca na d ia n F ra ilty Ne two rk to stud y d e pre sc rib ing a nd c o -c re a to r o f Me d Sa fe r, a to o l to sto p me d ic a tio ns in o ld e r a d ults (pa te nt pe nd ing )
mo ne y/ me rc ha nd ise
irst writte n re fe re nc e : in a nc ie nt Ind ia n me d ic a l te xts, physic ia n a nd surg e o n Susruta (c irc a 600 BCE ) d e sc rib e s a pa tie nt with a pa inful swo lle n le g tha t is d iffic ult to tre a t.
re nc h pa tho lo g ist, pro po se d a c e ntra l ro le fo r ve no us infla mma tio n a nd thro mb o sis in a ll d ise a se c o nd itio ns “phle b itis d o mina te s a ll o f pa tho lo g y”
se nsitive no r spe c ific
K G (S1Q3T 3), CXR (we ste rma rk’ s sig n a nd Ha mpto n’ s hump), physic a l e xa m
Re f: Da le n JE , Alpe rt JS. Na tura l histo ry o f pulmo na ry e mb o lism. Pro g Ca rdio va sc Dis 1975;17:259–70
ung sc a n (1960s)
a ng io g ra m e xc lud e s c linic ally r
e le vant PE
.
b y CT a ng io g ra m sinc e 2000 in E uro pe a nd 2006 in No rth Ame ric a
97%)
pre d ic tive va lue o f 85 to 90%)
pa tie nts
D stud y (1990 JAMA)--> the impo rta nc e o f pre -te st pro b a b ility
c linic a l pro b a b ility a nd a hig h pro b a b ility sc a n e q ua ting to the pre se nc e o f PE a nd a lo w c linic al pro b a b ility with a lo w pro b a b ility sc a n e xc lud ing PE
De spite PIOPE
D 2, c o nc e rns a b o ut spe c ific ity o f V/ Q
re po rting po sitive o r ne g a tive finding s in sha de s of g r
a y
Only dia g no stic in 30 to 50% o f pa tie nts Clinic ia ns c o ntinue d to se a rc h fo r a ye s/ no te st fo r a c ute PE
CT CT rapidl idly evolv lved t to fill t ll this rol
We re it no t fo r de finite a lle r
g ic a nd ne phr
isks o f
c o ntra st me dia a nd the a dde d r
a dia tion b urde n o f MDCT
A, the ve ntila tio n/ pe rfusio n sc a n wo uld virtua lly disa ppe a r fro m the dia g no stic a lg o rithm fo r pulmo na ry e mb o lism.
sc a nning fo r c e ntra l PE . T he stud y c o nc lud e d tha t spira l CT ha d a se nsitivity o f 100% a nd spe c ific ity o f 96% fo r a d ia g no sis o f c e ntra l PE .
se nsitivity 86%, spe c ific ity 92%, a nd like liho o d ra tio 10.7.
e inc lude d, howe ve r , se nsitivity was 63% , spe c ific ity 89% , and like lihood r atio 5.7.
With this in mind le t’ s c o nside r a c a se
c o ntra c e ptive pill pre se nts to a c o mmunity c linic a fte r a flig ht ho me fro m F ra nc e with ne w le ft c a lf pa in
a nd PE ” ( like ly b e c a use o f the histo ry
pulmo na ry a ng io g ra m is pe rfo rme d
ast is le ss than ade quate fo r a sse ssing se g me nta l a nd sub se g me nta l
b ra nc he s. No filling d e fe c ts id e ntifie d within the ma in pulmo na ry a rte rie s.
he re is a q ue stio na b le filling d e fe c t in a la te ra l lo we r lo b e se g me nta l b ra nc h se e ima g e 151 se rie s 5.
re c o mme nd a re pe at e xaminatio n in this patie nt o r a ve ntilatio n pe rfusio n sc an.
F a lse Po sitive Appa re nt filling de fe c ts L ung windo w re ve a ls mo tio n a rtifa c t
F a lse Po sitive / Re pro d uc ib ility
T he r e is r e lative ly poor inte r
ve r agr e e me nt for subse gme ntal and/ or small pulmonar y ar te r y de fe c ts, e spe c ially in CT pulmonar y angiogr ams de gr ade d by te c hnic al ar tifac ts.
PA a s first-line ima g ing fo r suspe c te d pulmo na ry e mb o lism c a n inc re a se the d e te c tio n o f sma ll, sub se g me nta l pulmo na ry e mb o lism, whic h mig ht ha ve a q ue stio na b le c linic al re le va nc e (fa lse po sitive / o ve rd ia g no sis)
PA a t a n a c a d e mic te a c hing ho spita l in Mo ntré a l, Ca na d a , fro m Se pte mb e r 2014 to Ja nua ry 2016.
de r e d by 182 physic ians we r e inc lude d, of whic h 199 (14.3% ) we r e positive. A multiva ria b le
lo g istic re g re ssio n a na lysis wa s pe rfo rme d to e xplo re whe the r physic ia n spe c ia lty, ye a rs in pra c tic e , physic ia n se x, o r to ta l numb e rs o f stud ie s o rd e re d pe r physic ia n we re a sso c ia te d with CT PA d ia g no stic yie ld .
Cho ng J, L e e T , Siva kuma ra n L , Ga llix B, Mc Dona ld E
G; a c c e pte d fo r pub lic a tio n
No v 1st, 2017; JAMA inte rna l me dic ine (IN PRE SS)
E lo g istic re g re ssio n, the odds of a positive CT
PA de c r e ase d as the total numbe r
de r e d pe r physic ian inc r e ase d.
e ac h additional te n studie s or de r e d, the odds of a positive r e sult de c r e ase d [OR 0.76; (95% CI 0.73- 0.79)].
Cho ng J, L e e T , Siva kuma ra n L , Ga llix B, Mc Dona ld E
G; a c c e pte d fo r pub lic a tio n
No v 1st, 2017; JAMA inte rna l me dic ine (IN PRE SS)
T ABL E 1: Positive CT PA E xa mina tions for All Physic ia ns T a b le o f the Numb e r o f Physic ia ns, Studie s, a nd Numb e r/ Pe rc e nta g e o f Po sitive CT PA with Ma jo r Spe c ia lty Gro uping s. Physic ia ns we re stra tifie d b y the to ta l study vo lume the y
Stud y Vo lume Numb e r o f Physic ia ns Numb e r o f CT PA Stud ie s Numb e r o f Po sitive CT PA (%) Physic ia n Sp e c ia lty Gro up : ER, Othe r (%) 1-10 145 411 85 (20.7) ER: 13 (9.0) Othe r: 132 (91.0) 11-20 14 228 37 (16.2) ER: 8 (57.1) Othe r: 6 (42.9) 21-30 9 198 30 (15.2) ER: 8 (88.9) Othe r: 1 (11.1) 31-40 6 179 20 (11.2) ER: 5 (83.3) Othe r: 1 (16.7) 41-50 5 219 19 (8.7) ER: 5 (100.0) > 50 3 159 8 (5.0) ER: 3 (100.0) T OT AL 182 1,394 199 (14.2) ER: 42 (23.1) Othe r: 140 (76.9)
Cho ng J, L e e T , Siva kuma ra n L , Ga llix B, Mc Donald E
G; a c c e pte d fo r pub lic a tio n: No v 1st, 2017;
JAMA inte rna l me dic ine (IN PRE SS)
T ABL E 1: Positive CT PA E xa mina tions for All Physic ia ns T a b le o f the Numb e r o f Physic ia ns, Studie s, a nd Numb e r/ Pe rc e nta g e o f Po sitive CT PA with Ma jo r Spe c ia lty Gro uping s. Physic ia ns we re stra tifie d b y the to ta l study vo lume the y
Stud y Vo lume Numb e r o f Physic ia ns Numb e r o f CT PA Stud ie s Numb e r o f Po sitive CT PA (%) Physic ia n Sp e c ia lty Gro up : ER, Othe r (%) 1-10 145 411 85 (20.7) ER: 13 (9.0) Othe r: 132 (91.0) 11-20 14 228 37 (16.2) ER: 8 (57.1) Othe r: 6 (42.9) 21-30 9 198 30 (15.2) ER: 8 (88.9) Othe r: 1 (11.1) 31-40 6 179 20 (11.2) ER: 5 (83.3) Othe r: 1 (16.7) 41-50 5 219 19 (8.7) ER: 5 (100.0) > 50 3 159 8 (5.0) ER: 3 (100.0) T OT AL 182 1,394 199 (14.2) ER: 42 (23.1) Othe r: 140 (76.9)
Cho ng J, L e e T , Siva kuma ra n L , Ga llix B, Mc Donald E
G; a c c e pte d fo r pub lic a tio n: No v 1st, 2017;
JAMA inte rna l me dic ine (IN PRE SS)
E ight e me r ge nc y r
e r e sponsible for
de r ing mor e than 1/ 3 of the institution’s sc ans! And the ir yie ld is L OW! <9%
stud ie s). Ho we ve r, c lo se r inspe c tio n d e mo nstra te d tha t the re wa s substantial inte r
iability, with ind ivid ua l positivity r ate s r anging be twe e n 0% to 33.3% .
AK E HOME ME SSAGE : Pe e r-re la tive ra te s o f utiliza tio n a re e a sily q ua ntifie d fro m e le c tro nic d a ta b a se s, a nd c a n id e ntify physic ia ns mo st like ly to b e ne fit fro m ind ivid ua l pe rfo rma nc e fe e d b a c k a nd d e c isio n suppo rt to o ls (a t the MUHC this a pro g ra m we a re wo rking o n instituting ).
Cho ng J, L e e T , Siva kuma ra n L , Ga llix B, Mc Dona ld E
G; a c c e pte d fo r pub lic a tio n
No v 1st, 2017; JAMA inte rna l me dic ine (IN PRE SS)
s a g o stra tify a c c o rding to a n o b je c tive
c linic a l pro b a b ility a sse ssme nt;
for low or inte r me dia te r isk
Re tro spe c tive ly re vie we d a ll lo we r e xtre mity Do pple r ultra so unds
pe rfo rme d o ve r a pe rio d o f 18 mo nths a t the Mo ntre a l Ge ne ra l Ho spita l, Ca na da . Physic ia ns o rde ring >10 e xa mina tio ns o ve r the study pe rio d we re inc lude d.
Ac ute DVT wa s ide ntifie d in 394/ 2030 studie s (16·5%). T he re wa s ma rke d va ria b ility in po sitivity ra te b y physic ia n (ra ng e 0%-42·9%). Of 79 pra c titio ne rs who o rde re d ≥10 e xa mina tio ns o ve r the study pe rio d, one in four a c hie ve d a positivity ra te a bove 15% , while one
in thre e ha d a positivity ra te be low 5% Mc Do na ld, Siva kuma ra n*, Cho ng , Ga llix, L e e ; unde r re vie w Annals o f I nte rnal Me dic ine *c o -first a utho r
10 20 30 40 50 60 ER Medicine Surgery
Proportion of physicians within a given range
Specialty 0% 1-10% 11-15% >15%
?
think this pa tie nt ha s a DVT
the n ST OP he re .
the n pro c e e d to use a c linic al pre d ic tio n to o l (e x. We ll’ s sc o re o r the PE RC sc o re )
d ime r o r a ppro pria te ima g ing
pulmo na ry a ng io g ra m (ind e te rmina te )
ne g a tive )
sub se q ue nt thre e mo nths
a nd no DVT , the g uid e line sug g e sts c linic al sur
ve illanc e ove r antic oagulation whe n the r isk of VT E r e c ur r e nc e is low
(Gra d e 2C).
he g uid e line re c o mme nd s the use o f a ntic o a g ula tio n
E re c urre nc e is hig h (Gra d e 2C).
r
SSPE s ar e antic oagulate d (72/ 82).
OF BL E E DING
OF BL E E DING
De sc rib e the ro o t o f the pro b le m: o ve rdia g no sis a nd
PA ha s be c ome mor e a nd mor e se nsitive a nd the r e is a n inc r e a se d de te c tion of PE
Ca se o f ve no us Do pple r a nd CT
pulmo na ry a ng io g ra m
Disc uss whe n a ntic o a g ula tio n ma y no t b e re q uire d Disc uss pra c titio ne r va ria b ility Re duc e o ve r-inve stig a tio n, o ve rdia g no sis a nd o ve rtre a tme nt
E within yo ur pra c tic e - a r
me d with this ne w knowle dg e , hope fully so!
se nsitivity a nd spe c ific ity)
ma nusc ript)
ro q ue t MD (d a ta - E R physic ia ns)
pa pe r)
izzy Smyth (d a ta c o lle c tio n)
ma nusc ript)
e e MD MPH (me nto rship a nd g uid a nc e )
e mily.mc do na ld@ mc g ill.c a