Objetivo: Verificar graus de concordância diagnóstica pela Angio-TC entre médicos da emergência, residentes de radiologia e radiologistas torácicos em casos suspeitos de tromboembolismo pulmonar (TEP). Material e Métodos: Foram retrospectivamente estudados 123 pacientes consecutivos com suspeita de TEP, de maço/2012 a fevereiro/2013, os quais realizaram Angio-TC pulmonar, obtida com colimação por multidetector 64x0,5. As imagens foram inicialmente interpretadas isoladamente por dois médicos da Emergência e por dois médicos residentes da Radiologia, e subsequentemente por dois Radiologistas Torácicos em consenso, verificando-se o grau de concordância interobservador entre eles quanto à presença de TEP. Resultados: O grau de concordância entre os Residentes da radiologia e os Radiologistas torácicos foi muito bom (Índice Kappa de 0,82 e 0,81); entre os Médicos da Emergência e os Radiologistas torácicos foi baixo ou moderado (Kappa de 0,37 e 0,42.), com um índice de 40,0% de relatos falso-positivos, aproximadamente. Aproximadamente 40,0% das interpretações falso-positivas correlacionaram-se principalmente com casos de TEP lobar e segmentar, enquanto que as falso-negativas ocorreram mais vezes com casos de TEP segmentar e subsegmentar. O grau de concordância geral entre todos os observadores mostrou-sei também moderado (Kappa de 0,50). Conclusão: Usando a Angio-TC no diagnóstico do TEP, o grau de concordância entre os radiologistas torácicos e os residentes da radiologia foi muito bom; entretanto, a concordância entre os médicos da emergência com os radiologistas torácicos foi baixa, com tendência a superestimar o diagnóstico da condição. / Purpose: To assess interobserver agreement rates between the Radiology resident, the thoracic radiologist and the Emergency physician for diagnosing pulmonary embolism (PE) in Computed Tomography Pulmonary Angiography (CTPA) examinations. Methods: Two Emergency physicians and two Radiology residents retrospectively evaluated 123 CTPA scans at our institution, and reported the presence of PE or not, individually. Two thoracic radiologists then reviewed the images, and a consensus was reached. Statistical analysis was performed, in order to provide the interobserver agreement. Results were expressed in kappa values for subsequent comparison. Results: Very good agreement in CTPA reading was observed between Radiology residents and thoracic radiologists (kappa index of 0.82 and 0.81). Fair and moderate agreement (kappa index of 0.39 and 0.42) was demonstrated between Emergency physicians and thoracic radiologists, with a rate of 40% false-positive reports, approximately, mainly in cases of both lobar and segmental involvement, whereas false-negative occurred more times in cases of segmental and subsegmental PE. The overall agreement was also moderate (kappa index of 0.50). Conclusion: The inter-observer agreement in CTPA examinations between radiology residents and thoracic radiologists in PE diagnoses was good, but it was low between the emergency physicians and the radiologists, with a tendency of overestimating that diagnoses.

Orientadores: Renato Giuseppe Giovanni Terzi, Ilma Aparecida Paschoal / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-12T22:30:15Z (GMT). No. of bitstreams: 1 Moreira_MarcosMello_D.pdf: 18313915 bytes, checksum: db1efb99a56b2256d14393f2e951147a (MD5) Previous issue date: 2009 / Resumo: Métodos para confirmar o diagnóstico de tromboembolismo pulmonar (TEP) são relativamente invasivos, de alto custo e nem sempre disponíveis. Justifica-se a busca de métodos mais acessíveis, de baixo custo, minimamente invasivos e que possam ser realizados à beira do leito. Foi objetivo deste estudo estabelecer um protocolo de triagem diagnóstica de TEP, minimamente invasivo e de baixo custo, usando para isto a capnografia volumétrica (CV) e o Oímero-O (DO) (ELISA Rápido), para pacientes internados em diferentes unidades de um hospital terciário, atentanto para as possíveis limitações deste protocolo. Foi realizado um estudo prospectivo e observacional com 92 pacientes. Um estudo prévio de CV em 114 voluntários estabeleceu o padrão de normalidade para as variáveis analisadas. No grupo TEP, a CV foi associada à gasometria arterial para cálculo das variáveis do espaço morto e à dosagem do DO. O padrão-ouro para diagnóstico de TEP foi dado pela cintilografia de inalação/perfusão e/ou, tomografia computadorizada helicoidal e/ou, arteriografia pulmonar. Isoladamente, a variável capnográfica que apresentou melhor sensibilidade e especificidade foi a fração tardia do espaço morto alveolar (tO/ate) (91% e 98%, respectivamente). Obteve-se um resultado falso-negativo para o DO e, para a tO/ate, um falso-positivo e três falso-negativos. Quando a tO/ate ,foi associada ao DO, conseguiu-se 100% sensibilidade e 17% de especificidade. Uma outra variável capnográfica importante, por sugerir função pulmonar prévia anormal, e por esta razão, sinalizar uma possível limitação da tO/ate, foi o slope da fase III do capnograma. Por meio dos dados da CV de ambos os grupos (controle e doentes), estabeleceu-se um protocolo que ajuda a direcionar a equipe multiprofissionál quando da suspeita clínica de TEP. / Abstract :Background: Tests used to confirm a diagnosis of pulmonary embolism (PE) are relatively invasive, costly and not always available. Minimally invasive methods that are more accessible, less expensive and easily applied should be sought. Objective: To establish a low-cost, minimally invasive, PE diagnostic protocol in hospitalized patients, using capnographic variables and ELlSA D-dimer (DD) to rule out PE. Methods: A prospective observational study was conducted in 92 patients with suspected PE. The values of reference group for volumetric capnography (VCap) were used in order to compare with patterns of patients with PE. The patients were submitted to arterial blood gas analysis (to calculate the dead space variables) and had the DD values determined. The diagnosis was confirmed through ventilation/perfusion scintigraphy, spiral computed tomography, pulmonary arteriogram, or combinations of the three. Results: The capnographic variable that presented the greatest sensitivity and specificity (91 % and 98%, respectively) was the late dead space fraction (fDlate). Our findings include one false-negative DD result, as well as three false-positive and eight false-negative fDlate results. The combination of the fDlate and DD testing presented 100% sensitivity and 17% specificity. Another important capnographic variable, the phase 111 slope, indicated a possible limitation of VCap, since it interferes with the calculation of fDlate. Conclusion: The protocol established could guide multiprofessional teams in the management of clinical suspicion of PE. We were able to determine that the phase 111 slope might interfere with the calculation of fDlate, especially in patients with a history of abnormal lung function. Throught VCap variables (control group and sickness); was possible establishes a protocol that guide the multiprofissional team in cases of PE. / Doutorado / Pesquisa Experimental / Doutor em Cirurgia

O diagnóstico da tromboembolia pulmonar aguda (EPA) e a avaliação da gravidade desta condição é desafiador. Enquanto as concentrações de troponina I cardíaca (TI) já estão bem estabelecidas quanto ao risco de estratificação, não há estudos prévios que tenham examinado se há alguma relação linear entre as concentrações de TI cardíaca e a gravidade da EPA. Além disso, as metaloproteinases (MMPs) da matriz extracelular estão envolvidas na fisiopatologia da EPA. Entretanto, é desconhecido se o aumento da atividade gelatinolítica das MMPs após a EPA reflete a gravidade desta condição. Nós examinamos se as concentrações circulantes destes biomarcadores aumentam em proporção à gravidade da EPA experimental induzida em cães anestesiados. A EPA foi induzida com coágulos de sangue autólogo (salina, 1, 3 ou 5 mL/Kg) injetados no átrio direito. As avaliações hemodinâmicas foram realizadas no momento basal e 120 minutos após a EPA. Da mesma forma, foram realizadas as quantificações de troponina I no soro e a zimografia das MMPs 2 e 9 no plasma. Nossos resultados sugerem não haver aumento significativo da atividade gelatinolítica da pró-MMP-2 no plasma após a EPA, enquanto que a atividade da pró-MMP-9 aumenta em 80% apenas no grupo que recebeu 5 mL/Kg de coágulos. A TI cardíaca no soro e a atividade da pró-MMP-9 no plasma tiveram uma correlação positiva com o índice de resistência vascular pulmonar (p=0,007 e rs=0,833 para a TI, e p=0,034 e rs=0,684 para a pró-MMP-9) e com a pressão média na artéria pulmonar (p=0,005 e rs=0,610 para a TI, e p=0,022 e rs=0,720 para a pró-MMP-9). Concluímos que a TI cardíaca e a pró-MMP-9 circulantes aumentam em proporção à gravidade da EPA, embora o aumento da pró-MMP-9 não seja muito evidente em graus menos severos da EPA. Estes achados podem ser relevantes para a clínica da EPA. / Making the diagnosis of acute pulmonary thromboembolism (APT) and assessing its severity is very challenging. While cardiac troponin I (CTI) levels are promising in risk stratification, no previous study has examined whether there is a linear relation between CTI levels and the severity of APT. Moreover, matrix metalloproteinases (MMPs) are involved in the pathophysiology of APT. However, it is unknown whether the increases in MMP levels after APT reflect the severity of this condition. We examined whether the circulating levels of these biomarkers increase in proportion to the severity of experimental APT induced in anesthetized dogs. APT was induced with autologous blood clots (saline, 1, 3, or 5 mL/kg) injected into the right atrium. Hemodynamic evaluations were carried out for 120 min. Gelatin zymography of MMP-2 and MMP-9 from plasma samples were performed and serum CTI levels were determined at baseline and 120 min after APT. Our results sugest that while no significant increases in pro-MMP-2 levels were found after APT, pro-MMP-9 levels increased by 80% only after 5 mL/kg of clot embolization. Serum CTI and plasma pro-MMP-9 levels correlated positively with pulmonary vascular resistance (p=0.007 and rs=0.833 for troponin I, and p=0.034 and rs=0.684 for pro-MMP-9) and with pulmonary artery pressure (p=0.005 and rs=0.610 for troponin I, and p=0.022 and rs=0.720 for pro-MMP-9). We conclude that circulating CTI and pro-MMP-9 increase in proportion to the severity of APT, although the increases in plasma pro-MMP-9 are less clear with less severe APT. These findings may be relevant for clinical APT.

Com a transição epidemiológica no Brasil, as doenças crônicas passaram a ser responsáveis pelo maior número de óbitos entre homens e mulheres. Entre os componentes que definem o estado de saúde humana, alguns do contexto geográfico, como clima local e fatores socioeconômicos, parecem influenciar na mortalidade por doenças do aparelho circulatório, tais como no acidente cerebral vascular (AVC) e na embolia pulmonar (EP). O objetivo principal deste trabalho foi verificar a influência do contexto geográfico (variáveis meteorológicas, índice climático e fatores socioeconômicos) na mortalidade por doenças do aparelho circulatório (AVC e EP) no município de São Paulo, no período de 2002 a 2011. Para analisar a associação da mortalidade com as variáveis meteorológicas foi utilizado um modelo linear generalizado empregando-se o método de Poisson e os modelos de lags distribuídos. Espacialmente a associação da mortalidade com as variáveis socioeconômicas foram testadas utilizando-se os modelos de regressão espacial OLS e GWR. Como resultado encontramos que tanto o frio quanto o calor são fatores de risco para todos os tipos de AVC e EP, com risco maior dependendo do tipo em homens e mulheres. Espacialmente os valores mais elevados do risco relativo (RR) da mortalidade por AVC estavam concentrados nas regiões periféricas do municipio de São Paulo, o que coincidiu com as áreas de menor renda per capita e vegetação e maior porcentagem de população preta. Já com relação à distribuição espacial dos altos valores de RR por EP esses estavam presentes principalmente na região central do município. Concluindo, a nossa pesquisa gerou grande quantidade de resultados que mostram que tanto as variáveis ambientais como socioeconômicas têm influência na mortalidade por algumas doenças do aparelho circulatório. Tendo em vista que o atendimento de urgência para os casos de AVC e EP pode evitar óbitos e sequelas graves, a melhor compreensão da importância do contexto geográfico pode permitir o desenvolvimento de sistemas de alertas junto aos serviços de atendimento de urgência e o direcionamento de campanhas para a prevenção dos fatores de risco evitáveis. / With the epidemiological transition in Brazil, chronic diseases are now responsible for more deaths among men and women. Among the components that define the state of human health, some geographical context, as local climate and socioeconomic factors appear to influence the mortality from circulatory diseases, such as in stroke and pulmonary embolism (PE). The main objective of this study was to investigate the influence of the geographical context (meteorological variables, climate index and socioeconomic factors) in mortality from cardiovascular diseases (stroke and PE) in São Paulo, between 2002 to 2011. In order to analyze the association of mortality with the meteorological variables we used a generalized linear model using the Poisson distribution and distributed lag non linear models. Spatially the association of mortality with socioeconomic variables were tested using the spatial regression models OLS and GWR. As a result we found that both the cold and the heat are risk factors for all types of stroke and PE with a higher risk depending on the type of men and women. Spatially the highest values of relative risk (RR) for stroke mortality were concentrated in the outskirts of the city of São Paulo, which coincided with areas of lower per capita income and vegetation and higher percentage of black population. In relation to spatial distribution of high values of RR PE by these were present mainly in the inner area. In conclusion, our research has generated a lot of results that show that both environmental and socioeconomic variables influence on mortality from some diseases of the circulatory system. In view of the urgent care for stroke and PE cases can avoid serious sequelae and deaths, a better understanding of the importance of geographic context may allow the development of warning systems at the urgent care services and targeting campaigns for the prevention of avoidable risk factors.

Les forêts du monde entier sont menacées de mortalités importantes lors de sécheresses intenses liés au changement climatique. Les conifères en particulier semblent extrêmement vulnérables à la mort par dysfonctionnement hydraulique de leur système vasculaire ou embolie. Le principal objectif de cette thèse est d’étudier la résistance à l’embolie des conifères dans un cadre évolutif. Premièrement, nous avons mis en évidence que la résistance à l’embolie varie d’un facteur neuf sur plus de 250 espèces parmi les 7 familles de conifères, atteignant un nouveau record du monde avec Callitris tuberculata (P50 = -18.8 MPa). Nous avons montré le lien évolutif entre cette résistance et l’anatomie des ponctuations aréolées. En combinant cette base de données unique avec une phylogénie calibrée de plus de 300 espèces, nous avons retracé la diversification des conifères et l’évolution de leur résistance à l’embolie. Nous avons découvert que plusieurs lignées de conifères ont brusquement changé de dynamiques évolutives, avec l’accélération de la spéciation et de l’évolution de résistance à l’embolie. En outre, les conifères plus résistants se sont diversifié plus rapidement, notamment les genres Cupressus, Juniperus et Callitris (Cupressaceae). La diversification de ces derniers s’est accélérée avec l’aridification de l’Australie sur les derniers 30 Millions d’années. Nous montrons que leur xylème a été façonné par la sécheresse, devenant plus résistant à l’embolie mais surtout sans compromettre l’efficience du transport de l’eau ou augmenter son coût de construction. Cette thèse élargit notre compréhension de l’évolution des plantes vasculaire face aux sécheresses intenses. / Forests worldwide are at increased risk of widespread mortality due to intense drought under current and future climate change. In particular, conifer species seem extremely vulnerable to mortality due to hydraulic failure or embolism. The main objective of this thesis was to examine conifer resistance to embolism in an evolutionary framework. Firstly, we uncovered 9-fold variation in resistance to embolism across 250 species from the 7 conifer families, culminating in a new world record in Callitris tuberculata (P50 = -18.8 MPa). We demonstrated the evolutionary relationship between increased embolism resistance and the anatomy of bordered pits. By combining this unprecedented physiological dataset with a time-calibrated phylogeny of over 300 species, we retraced conifer diversification and the evolution of embolism resistance. We discovered multiple evolutionary dynamics with several conifer lineages shifting to higher rates of speciation and trait evolution. We found that conifers with high drought resistance diversified more rapidly, especially crown groups of Cupressaceae composed of the Cupressus-Juniperus clade and the Callitris clade. Within this last group, diversification rates increased over the course of the aridification of Australia over the last 30 million years. We show how their xylem has been shaped by drought, becoming more resistant to embolism, but crucially we found no trade-off with water transport efficiency or construction costs. This work greatly expands our understanding of how vascular plants have evolved to cope with extreme drought.

Objective: To report a case of deep vein thrombosis (DVT) with symptomatic pulmonary embolism (PE) possibly associated with the use of coltsfoot, kava, or blue vervain. Case Summary: A 27-year-old white male presented with leg pain and swelling, tachycardia, and pleuritic chest pain. He had no significant medical history. A medication history revealed extensive herbal medication use including: coltsfoot, passionflower, red poppy flower petals, wild lettuce, blue lily flowers, wild dagga flowers, Diviners Three Burning Blend® (comprised of salvia divinorum, blue lily, and wild dagga), kavakava, St. John's Wort, blue vervain, and Dreamer's Blend® (comprised of Calea zacatechichi, vervain, Entada rheedii, wild lettuce, and Eschscholzia californica). Lower extremity Doppler ultrasound and computed topography (CT) of the chest revealed DVT and PE. A hypercoagulable work-up was negative. The patient was treated with enoxaparin and warfarin and was discharged home. Discussion: While no distinct agent can be identified as a sole cause of this venous thromboembolic event, coltsfoot could potentially affect coagulation through its effect on vascular endothelial cells as they regulate nitric oxide. Nitric oxide is a known mediator of platelet activity and coagulation, particularly in the pulmonary vasculature. Kava and vervain have estrogenic properties. Conclusions: Of the medications consumed by this self-proclaimed "herbalist," coltsfoot is a potential cause of venous thromboembolic disease (VTE).

Patients with inflammatory bowel disease (IBD) are known to have an increased propensity for thromboembolic events. Like any patient with a high risk of event recurrence, most of these patients can be managed successfully with long-term warfarin therapy. We present the case of a 66-year-old woman with Crohn's disease who, despite careful attention to the management of her international normalized ratio, developed a new deep vein thrombosis and required inferior vena cava filter placement in addition to ongoing warfarin therapy to prevent recurrent pulmonary emboli. This report serves as a reminder to physicians to have a low threshold for diagnosing thromboembolic events in patients with IBD, even if they are presumed to be adequately anticoagulated. Known and theoretical contributing factors to this increased clotting tendency are also reviewed.

Background: Recent studies have suggested that patients with idiopathic pulmonary fibrosis (IPF) may have a higher risk of venous thromboembolism (VTE) compared to general population even though the results were inconsistent. Objective: To investigate the risk of VTE among patients with IPF. Methods: Comprehensive literature review using MEDLINE and EMBASE database were performed to identify studies that compared the risk of VTE among patients with IPF to general population. Effect estimates from each study were combined together using random effect model, generic inverse variance method of DerSimonian and Laird. Results: Out of 510 retrieved articles, 5 studies met the inclusion criteria and were included in the meta-analysis. A significant risk of VTE in patients with IPF was observed with the pooled risk ratio of 2.11 (95% confidence interval, 1.28-3.48). The heterogeneity was moderate with I2 of 64%. Conclusion: An approximately 2-fold increased risk of VTE among patients with IPF was observed in this meta-analysis.

Relation between the reperfusion of pulmonary arteries after acute pulmonary embolism to the development of chronic thromboembolic pulmonary hypertension Incomplete resolution of thromboemboli following acute pulmonary embolism (PE) is a key factor in development of chronic thromboembolic pulmonary hypertension (CTEPH). In our study, we evaluated the incidence, risk factors and clinical impact of incomplete reperfusion after acute PE. Study population and methods: 85 patients after the first acute PE were assessed clinically and by pulmonary scintigraphy and echocardiography at month 6, 12 and 24 after an acute PE. Results: Incomplete reperfusion was detected in 23.5 % of patients after 6 months, in 24.9 % of patients after 12 months and in 18.6 % of patients after 24 months. At month 6, patients with incomplete reperfusion were more obese when compared with patients with normal reperfusion BMI 30.8 vs 28.3 kg/m2 ; p=0.012) and their initial hemoglobin levels were higher (143.0 vs 136.0 g/l; p=0.012). Similar results were observed at month 12 - patients with residual perfusion defects were more obese (BMI 31.1 vs 28.5; p=0.016) with higher initial hemoglobin levels (144.0 vs 136.0; p=0.007). Patients with incomplete reperfusion at month 24 were significantly older (67.7 vs 55.0 years; p=0.02), their...

BACKGROUND: South Africa bares a significant burden of HIV and imaging is commonly performed as part of the workup for respiratory distress. OBJECTIVES: The aim of this study was to document the prevalence of pulmonary thrombo-embolic disease (PTED) and other findings in HIV-infected patients referred for CT pulmonary angiography (CTPA) for suspected PTED. METHOD: Forty CTPA studies of documented HIV-infected individuals investigated for suspected PTED during a 1-year period were retrieved, anonymised and interpreted by three consultant radiologists. Inter-reader reliability was calculated using Free Marginal multi-rater Kappa. RESULTS: Fourteen of the forty cases (35%) were positive for PTED. In the pulmonary embolism (PE)-positive group, 57.14% had peripheral disease and 42.86% had both peripheral and central disease. Associated findings in the PE-positive cases were pulmonary infarcts (17.5%), mosaic attenuation (17.5%) and linear atelectasis (7.5%). The most common incidental findings were solid pulmonary nodules (52.5%), non-wedge-shaped consolidation (45%), cardiomegaly (52.5%) and enlarged intra-thoracic lymph nodes (52.5%). Thirty per cent of the study population had findings related directly to the presence of PTED, whilst most cases in the study (77.5%) had pulmonary findings unrelated to PTED. In the PE-negative cases, 55% reported emergent findings that warranted immediate or urgent medical attention. CONCLUSION: Computed tomography pulmonary angiography imaging is critical for diagnosing PE. However, further investigation into the judicious application of CTPA in HIV-infected patients with suspected PTED is required, as CTPA findings in most of the cases in this study were unrelated to PE.