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Andrea Penaloza - One of the best experts on this subject based on the ideXlab platform.
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comparison of the Wells Score and the revised geneva Score as a tool to predict pulmonary embolism in outpatients over age 65
Thrombosis Research, 2020Co-Authors: Julien Coelho, Pierre-marie Roy, Andrea Penaloza, Margaux Divernetqueriaud, Gregoire Le Gal, A TrinhducAbstract:Abstract Title Comparison of the Wells Score and the revised Geneva Score as a tool to predict pulmonary embolism in outpatients over 65 years of age. Introduction The incidence and mortality of pulmonary embolism (PE) is high in the elderly. The Wells Score (SW) and the revised Geneva Score (RGS) have been validated in patient populations with a large age range. The aim of this study was to compare the predictive accuracy of these two Scores in diagnosis of PE in patients over 65 years of age. Method A prospective multicentre study (nine French and three Belgian centres) was conducted at the same time as the PERCEPIC study. A total of 1757 patients admitted with suspected PE were included and divided into two groups according to age (≥65 years or Results The overall prevalence of PE was 11.3%. The prevalence among patients aged ≥65 in the low, moderate and high pre-test probability groups, evaluated using the WS and was respectively 13.5% (CI 95%: CI 9.9–17.3), 28.2% (CI 22.1–34.3), 50% (CI 26–74) and 8.1% (CI 3.2–12.9), 22.3% (CI 18.2–26.3), 43.7% (CI 25.6–61.9) using the RGS. The AUC for the WS and RGS for patients aged ≥65 was 0.632 (CI 0.574–0.691) and 0.610 (CI 0.555–0.666). The difference between the AUCs was not statistically significant (p = .441). Conclusion In the population for this study, the WS and RGS have the same PE diagnostic accuracy in patients over age 65. This result should be validated in a prospective study that directly compares these Scores.
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comparison of the unstructured clinician gestalt the Wells Score and the revised geneva Score to estimate pretest probability for suspected pulmonary embolism
Annals of Emergency Medicine, 2013Co-Authors: Andrea Penaloza, Franck Verschuren, Guy Meyer, Sybille Quentingeorget, Caroline Soulie, Frederic Thys, Pierre-marie RoyAbstract:Study objective: The assessment of clinical probability (as low, moderate, or high) with clinical decision rules has become a cornerstone of diagnostic strategy for patients with suspected pulmonary embolism, but little is known about the use of physician gestalt assessment of clinical probability. We evaluate the performance of gestalt assessment for diagnosing pulmonary embolism. Methods: We conducted a retrospective analysis of a prospective observational cohort of consecutive suspected pulmonary embolism patients in emergency departments. Accuracy of gestalt assessment was compared with the Wells Score and the revised Geneva Score by the area under the curve (AUC) of receiver operating characteristic curves. Agreement between the 3 methods was determined by κ test. Results: The study population was 1,038 patients, with a pulmonary embolism prevalence of 31.3%. AUC differed significantly between the 3 methods and was 0.81 (95% confidence interval [CI] 0.78 to 0.84) for gestalt assessment, 0.71 (95% CI 0.68 to 0.75) for Wells, and 0.66 (95% CI 0.63 to 0.70) for the revised Geneva Score. The proportion of patients categorized as having low clinical probability was statistically higher with gestalt than with revised Geneva Score (43% versus 26%; 95% CI for the difference of 17%=13% to 21%). Proportion of patients categorized as having high clinical probability was higher with gestalt than with Wells (24% versus 7%; 95% CI for the difference of 17%=14% to 20%) or revised Geneva Score (24% versus 10%; 95% CI for the difference of 15%=13% to 21%). Pulmonary embolism prevalence was significantly lower with gestalt versus clinical decision rules in low clinical probability (7.6% for gestalt versus 13.0% for revised Geneva Score and 12.6% for Wells Score) and non-high clinical probability groups (18.3% for gestalt versus 29.3% for Wells and 27.4% for revised Geneva Score) and was significantly higher with gestalt versus Wells Score in high clinical probability groups (72.1% versus 58.1%). Agreement between the 3 methods was poor, with all κ values below 0.3. Conclusion: In our retrospective study, gestalt assessment seems to perform better than clinical decision rules because of better selection of patients with low and high clinical probability.
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comparison of the Wells Score with the simplified revised geneva Score for assessing pretest probability of pulmonary embolism
Thrombosis Research, 2011Co-Authors: Andrea Penaloza, Christian Melot, Serge MotteAbstract:INTRODUCTION: The Wells Score is widely used in the assessment of pretest probability of pulmonary embolism (PE). The revised Geneva Score is a fully standardized clinical decision rule that was recently validated and further simplified. We compared the predictive accuracy of these two Scores. METHODS: Data from 339 patients clinically suspected of PE from two prospective management studies were used and combined. Pretest probability of PE was assessed prospectively by the Wells Score. The simplified revised (SR) Geneva Score was calculated retrospectively. The predictive accuracy of both Scores was compared by area under the curve (AUC) of receiver operating characteristic (ROC) curves. RESULTS: The overall prevalence of PE was 19%. Prevalence of PE in the low, moderate and high pretest probability groups assessed by the Wells Score and by the simplified revised Geneva Score was respectively 2%(95% CI (CI) 1-6) and 4% (CI 2-10), 28% (CI 22-35) and 25% (CI 20-32), 93% (CI 70-99) and 56% (CI 27-81). The Wells Score performed better than the simplified revised Geneva Score in patients with a high suspicion of PE (p<0.05). The AUC for the Wells Score and the simplified revised Geneva Score was 0.85 (CI: 0.81 to 0.89) and 0.76 (CI: 0.71 to 0.80) respectively. The difference between the AUCs was statistically significant (p=0.005). CONCLUSIONS: In our population the Wells Score appeared to be more accurate than the simplified revised Geneva Score. The impact of this finding in terms of patient outcomes should be investigated in a prospective study.
Sujith V Cherian - One of the best experts on this subject based on the ideXlab platform.
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Wells Score to predict pulmonary embolism in patients with coronavirus disease 2019
The American Journal of Medicine, 2021Co-Authors: Brittany Kirsch, Moez Karim Aziz, Sungita Kumar, Michael Burke, Tyler Webster, Amrutha Immadi, Maurine Sam, Aditya P Lal, Rosa M Estradaymartin, Sujith V CherianAbstract:Abstract Background The association between coronavirus disease 2019 (COVID-19) and hypercoagulability has been extensively described, and pulmonary embolism is a recognized complication of COVID-19. Currently, the need for computed tomography pulmonary angiogram (CTPA) relies on the Wells Score and serum D-dimer levels. However, because COVID-19 patients have a different thrombotic and inflammatory milieu, the usefulness of the Wells Score deserves further exploration for this patient population. We aimed to explore the ability of the Wells Score to predict pulmonary embolism in patients with COVID-19. Methods In this retrospective study, patients found to have a CTPA and a COVID-19 diagnosis during the same admission were selected for analysis. Age and sex, CTPA results, and associated D-dimer levels were entered in a database. The Wells Score sensitivity and specificity were calculated at different values, and the area under the curve of the receiver operating characteristic curve measured. Results Of 459 patients with COVID-19, 64 had a CTPA and 12 (19%) had evidence of pulmonary embolism. Previous or current evidence of deep vein thrombosis, a Wells Score above 4 points, and serum D-dimer levels 5 times above age-adjusted upper normal values were associated with pulmonary embolism. However, only 33% of patients with pulmonary embolism had a Wells Score of 4 points or higher. The area under the curve of the receiver operating characteristic showed non-discriminating values (0.54) Conclusions Although a Wells Score of 4 or more points predicted pulmonary embolism in our cohort, the outcome can be present even with lower Scores.
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Wells Score to predict pulmonary embolism in patients with coronavirus disease 2019
Social Science Research Network, 2020Co-Authors: Brittany Kirsch, Moez Karim Aziz, Sungita Kumar, Michael Burke, Tyler Webster, Amrutha Immadi, Maurine Sam, Aditya P Lal, Rosa M Estradaymartin, Sujith V CherianAbstract:Background: Deep vein thromboses (DVT) and pulmonary embolism (PE) are recognized complications of Coronavirus Disease 2019 (COVID-19). Currently, the need for Computed Tomography Pulmonary Angiogram (CTPA) relies on the Wells Score together with serum D-dimer levels. However, since COVID-19 patients have a different thrombotic and inflammatory milieu, the usefulness of the Wells Score deserves further exploration among these patients. We aimed to explore the ability of the Wells Score to predict pulmonary embolism in patients with COVID-19. Methods: In this retrospective cohort of patients with COVID-19, patients that had a CTPA were selected for analysis. A nested case-control design searched for differences between patients with and without PE. Patients’ age and gender, CTPA results, and associated D-dimer levels were collected. The Wells Score sensitivity and specificity were calculated at different values, and an area under the curve of a receiver operating characteristic curve (AUC/ROC) measured. Findings: Of 459 patients with COVID-19, 64 had a CTPA performed during the hospital visit and 12 (19%) had evidence of PE. Previous or current evidence of DVT, a Wells Score above four points, and serum D-dimer levels five times above age-adjusted upper normal values were associated with PE. However, only 33% of patients with PE had a Wells Score of four points or higher. The AUC/ROC showed non-discriminating values (0·54). Interpretation: While a Wells Score of four or more points predicted PE in our cohort, the outcome can be present even with lower Scores. Serum D-dimer elevation also predicted PE, but in the setting of COVID-19 this feature may reflect the severity of disease, regardless of demonstrable thrombosis. Funding Statement: This retrospective study was unfunded. Declaration of Interests: None of the authors have conflicts of interest to report. Ethics Approval Statement: The study was approved by the University of Texas at Houston IRB committee (HSCMS-20-0542). A written informed consent for this study was waived.
Pierre-marie Roy - One of the best experts on this subject based on the ideXlab platform.
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comparison of the Wells Score and the revised geneva Score as a tool to predict pulmonary embolism in outpatients over age 65
Thrombosis Research, 2020Co-Authors: Julien Coelho, Pierre-marie Roy, Andrea Penaloza, Margaux Divernetqueriaud, Gregoire Le Gal, A TrinhducAbstract:Abstract Title Comparison of the Wells Score and the revised Geneva Score as a tool to predict pulmonary embolism in outpatients over 65 years of age. Introduction The incidence and mortality of pulmonary embolism (PE) is high in the elderly. The Wells Score (SW) and the revised Geneva Score (RGS) have been validated in patient populations with a large age range. The aim of this study was to compare the predictive accuracy of these two Scores in diagnosis of PE in patients over 65 years of age. Method A prospective multicentre study (nine French and three Belgian centres) was conducted at the same time as the PERCEPIC study. A total of 1757 patients admitted with suspected PE were included and divided into two groups according to age (≥65 years or Results The overall prevalence of PE was 11.3%. The prevalence among patients aged ≥65 in the low, moderate and high pre-test probability groups, evaluated using the WS and was respectively 13.5% (CI 95%: CI 9.9–17.3), 28.2% (CI 22.1–34.3), 50% (CI 26–74) and 8.1% (CI 3.2–12.9), 22.3% (CI 18.2–26.3), 43.7% (CI 25.6–61.9) using the RGS. The AUC for the WS and RGS for patients aged ≥65 was 0.632 (CI 0.574–0.691) and 0.610 (CI 0.555–0.666). The difference between the AUCs was not statistically significant (p = .441). Conclusion In the population for this study, the WS and RGS have the same PE diagnostic accuracy in patients over age 65. This result should be validated in a prospective study that directly compares these Scores.
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comparison of the unstructured clinician gestalt the Wells Score and the revised geneva Score to estimate pretest probability for suspected pulmonary embolism
Annals of Emergency Medicine, 2013Co-Authors: Andrea Penaloza, Franck Verschuren, Guy Meyer, Sybille Quentingeorget, Caroline Soulie, Frederic Thys, Pierre-marie RoyAbstract:Study objective: The assessment of clinical probability (as low, moderate, or high) with clinical decision rules has become a cornerstone of diagnostic strategy for patients with suspected pulmonary embolism, but little is known about the use of physician gestalt assessment of clinical probability. We evaluate the performance of gestalt assessment for diagnosing pulmonary embolism. Methods: We conducted a retrospective analysis of a prospective observational cohort of consecutive suspected pulmonary embolism patients in emergency departments. Accuracy of gestalt assessment was compared with the Wells Score and the revised Geneva Score by the area under the curve (AUC) of receiver operating characteristic curves. Agreement between the 3 methods was determined by κ test. Results: The study population was 1,038 patients, with a pulmonary embolism prevalence of 31.3%. AUC differed significantly between the 3 methods and was 0.81 (95% confidence interval [CI] 0.78 to 0.84) for gestalt assessment, 0.71 (95% CI 0.68 to 0.75) for Wells, and 0.66 (95% CI 0.63 to 0.70) for the revised Geneva Score. The proportion of patients categorized as having low clinical probability was statistically higher with gestalt than with revised Geneva Score (43% versus 26%; 95% CI for the difference of 17%=13% to 21%). Proportion of patients categorized as having high clinical probability was higher with gestalt than with Wells (24% versus 7%; 95% CI for the difference of 17%=14% to 20%) or revised Geneva Score (24% versus 10%; 95% CI for the difference of 15%=13% to 21%). Pulmonary embolism prevalence was significantly lower with gestalt versus clinical decision rules in low clinical probability (7.6% for gestalt versus 13.0% for revised Geneva Score and 12.6% for Wells Score) and non-high clinical probability groups (18.3% for gestalt versus 29.3% for Wells and 27.4% for revised Geneva Score) and was significantly higher with gestalt versus Wells Score in high clinical probability groups (72.1% versus 58.1%). Agreement between the 3 methods was poor, with all κ values below 0.3. Conclusion: In our retrospective study, gestalt assessment seems to perform better than clinical decision rules because of better selection of patients with low and high clinical probability.
A. Cozzi - One of the best experts on this subject based on the ideXlab platform.
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pulmonary thromboembolism in hospitalised covid 19 patients at moderate to high risk by Wells Score a report from lombardy italy
British Journal of Radiology, 2020Co-Authors: L. Monfardini, M. Morassi, P. Botti, R. Stellini, L. Bettari, S. Pezzotti, M. Ali, C.g. Monaco, V. Magni, A. CozziAbstract:Objectives:To present a single-centre experience on CT pulmonary angiography (CTPA) for the assessment of hospitalised COVID-19 patients with moderate-to-high risk of pulmonary thromboembolism (PTE...
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Pulmonary thromboembolism in hospitalised COVID-19 patients at moderate to high risk by Wells Score: a report from Lombardy, Italy
'British Institute of Radiology', 2020Co-Authors: L. Monfardini, M. Morassi, P. Botti, R. Stellini, L. Bettari, S. Pezzotti, M. Ali, C.g. Monaco, V. Magni, A. CozziAbstract:OBJECTIVES: To present a single-centre experience on CT pulmonary angiography (CTPA) for the assessment of hospitalised COVID-19 patients with moderate-to-high risk of pulmonary thromboembolism (PTE). METHODS: We analysed consecutive COVID-19 patients (RT-PCR confirmed) undergoing CTPA in March 2020 for PTE clinical suspicion. Clinical data were retrieved. Two experienced radiologists reviewed CTPAs to assess pulmonary parenchyma and vascular findings. RESULTS: Among 34 patients who underwent CTPA, 26 had PTE (76%, 20 males, median age 61 years, interquartile range 54-70), 20/26 (77%) with comorbidities (mainly hypertension, 44%), and 8 (31%) subsequently dying. Eight PTE patients were under thromboprophylaxis with low-molecular-weight heparin, four PTE patients had lower-limbs deep vein thrombosis at ultrasound examination (performed in 33/34 patients). Bilateral PTE characterised 19/26 cases, with main branches involved in 10/26 cases. Twelve patients had a parenchymal involvement >75%, the predominant pneumonia pattern being consolidation in 10/26 patients, ground glass opacities in 9/26, crazy paving in 5/26, and both ground glass opacities and consolidation in 2/26. CONCLUSION: COVID-19 patients are prone to PTE. ADVANCES IN KNOWLEDGE: PTE, potentially attributable to an underlying thrombophilic status, may be more frequent than expected in COVID-19 patients. Extension of prophylaxis and adaptation of diagnostic criteria should be considered
Ramin Khorasani - One of the best experts on this subject based on the ideXlab platform.
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yield of ct pulmonary angiography in the emergency department when providers override evidence based clinical decision support
Radiology, 2017Co-Authors: Zihao Yan, Ali S Raja, Anurag Gupta, Joshua M Kosowsky, Ramin KhorasaniAbstract:Purpose To determine the frequency of, and yield after, provider overrides of evidence-based clinical decision support (CDS) for ordering computed tomographic (CT) pulmonary angiography in the emergency department (ED). Materials and Methods This HIPAA-compliant, institutional review board-approved study was performed at a tertiary care, academic medical center ED with approximately 60 000 annual visits and included all patients who were suspected of having pulmonary embolism (PE) and who underwent CT pulmonary angiography between January 1, 2011, and August 31, 2013. The requirement to obtain informed consent was waived. Each CT order for pulmonary angiography was exposed to CDS on the basis of the Wells criteria. For patients with a Wells Score of 4 or less, CDS alerts suggested d-dimer testing because acute PE is highly unlikely in these patients if d-dimer levels are normal. The yield of CT pulmonary angiography (number of positive PE diagnoses/total number of CT pulmonary angiographic examinations) was compared in patients in whom providers overrode CDS alerts (by performing CT pulmonary angiography in patients with a Wells Score ≤4 and a normal d-dimer level or no d-dimer testing) (override group) and those in whom providers followed Wells criteria (CT pulmonary angiography only in patients with Wells Score >4 or ≤4 with elevated d-dimer level) (adherent group). A validated natural language processing tool identified positive PE diagnoses, with subsegmental and/or indeterminate diagnoses removed by means of chart review. Statistical analysis was performed with the χ2 test, the Student t test, and logistic regression. Results Among 2993 CT pulmonary angiography studies in 2655 patients, 563 examinations had a Wells Score of 4 or less but did not undergo d-dimer testing and 26 had a Wells Score of 4 or less and had normal d-dimer levels. The yield of CT pulmonary angiography was 4.2% in the override group (25 of 589 studies, none with a normal d-dimer level) and 11.2% in the adherent group (270 of 2404 studies) (P < .001). After adjustment for the risk factor differences between the two groups, the odds of an acute PE finding were 51.3% lower when providers overrode alerts than when they followed CDS guidelines. Comparison of the two groups including only patients unlikely to have PE led to similar results. Conclusion The odds of an acute PE finding in the ED when providers adhered to evidence presented in CDS were nearly double those seen when providers overrode CDS alerts. Most overrides were due to the lack of d-dimer testing in patients unlikely to have PE. © RSNA, 2016.
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performance of Wells Score for deep vein thrombosis in the inpatient setting
JAMA Internal Medicine, 2015Co-Authors: Patricia C Silveira, Samuel Z Goldhaber, Gregory Piazza, Carol B Benson, Ramin KhorasaniAbstract:Importance The Wells Score to determine the pretest probability of deep vein thrombosis (DVT) was validated in outpatient settings, but it is unclear whether it applies to inpatients. Objective To evaluate the utility of the Wells Score for risk stratification of inpatients with suspected DVT. Design, Setting, and Participants A prospective study was conducted in a 793-bed quaternary care, academic hospital using Wells Score clinical predictor findings entered by health care professionals in a computerized physician order entry system at the time lower-extremity venous duplex ultrasound studies were ordered. All adult inpatients suspected of having lower-extremity DVT who underwent lower-extremity venous duplex ultrasound studies between November 1, 2012, and December 31, 2013, were included. Patients with DVT diagnosed within the prior 3 months were excluded. For patients undergoing multiple lower-extremity venous duplex ultrasound studies, only the first was included. Main Outcomes and Measures Our primary outcome was the Wells Score’s utility for risk stratification among inpatients with suspected DVT as measured by the difference in incidence of proximal DVT among the 3 Wells Score categories (low, moderate, and high pretest probability), the discrimination accuracy of the Wells Score categories as the area under the receiver operating characteristics curve, the failure rate of Wells Score prediction, and the efficiency of the Wells Score to exclude DVT. Results In a study cohort of 1135 inpatients, 137 (12.1%) had proximal DVT. Proximal DVT incidence in low, moderate, and high pretest probability groups was 5.9% (8 of 135), 9.5% (48 of 506), and 16.4% (81 of 494), respectively ( P Conclusions and Relevance The Wells Score performed only slightly better than chance for discrimination of risk for DVT in hospitalized patients. It had a higher failure rate and a lower efficiency in the inpatient setting compared with that reported in the outpatient literature. Therefore, the Wells Score risk stratification is not sufficient to rule out DVT or influence management decisions in the inpatient setting.