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EVALUATION OF THE DIAGNOSTIC EFFICIENCY OF PULMONARY CT ANGIOGRAPHY EXAMINATION AT EMERGENCY DEPARTMENT

Yıl 2022, Cilt: 8 Sayı: 3, 281 - 290, 01.09.2022
https://doi.org/10.53394/akd.1059369

Öz

Purpose:
The use of advanced medical imaging in the emergency department (ED) has increased substantially. With this rapid increase; the possibility of both the low diagnostic efficiency of these imaging methods; as well as the possible damages that may occur due to these methods. In this regard, the use of pulmonary computed tomography angiography (pulmonary CTA), which is one of the advanced imaging methods in patients with suspected pulmonary embolism (PE), stands out.
Acute PE is an important cause of morbidity and mortality worldwide.
In this study, we aimed to investigate the diagnostic efficiency of pulmonary CTA in patients who applied to Çanakkale Onsekiz Mart University Hospital Emergency Service and requested pulmonary CTA with a pre-diagnosis of PE.
Material -method:
After ethics committee approval this study was carried out by retrospectively examining the radiological images and medical records of patients who were admitted to Çanakkale Onsekiz Mart University Emergency Department between January 2016 and June 2018, and requested pulmonary CTA examination with a pre-diagnosis of PE,
The clinical information of the patients included in the study were examined by two emergency room doctors; and radiological images by two radiologist blindly.
Study data were analyzed using SPSS 19 package program. Mann Whitney U test was used for comparison of numerical variables and Chi-Square test was used for comparison of categorical variables. İn the interpretation os statistical data, p< 0.05 was considered significant.
Results:
İn this study, a total of 233 patients who were admitted to the emergency department between January 01 2016- June 01 2018 and had pulmonary CTA with a pre-diagnosis of PE were identified. Eleven of the patients were excluded from the study because of insufficient pulmonary CTA image quality due to artifacts. The data of the remaining 222 patients were analyzed. While pulmonary embolisim was found in 19 (8.6%) patients (Group-1), pulmonary embolisim was not found in 203 (91.4%) patients (Group-2). No pathology was observed in two (0.9%) of the patients without embolism and reported as normal.
İn both groups, the patients most frequently applied to the emergency department with complaints of shortness of breath and secondly, chest pain.
Although the D-Dimer values of the patients were above normal in all patients; found higher in group-1 than group-2 (6.42 ± 8.02 µg/L in Group-1; 2.38 ± 1.99 µg/L in Group-2 N:< 0.5 µg/L). However, the finding was not statistically significant (p> 0.05; Table-2).
Platelet count and lactate value was higher in patients with PE (Group-1) compared to patients without PE (Group-2) (341.71 ± 146.23, 263.72 ± 107.28 cells / ml; 5.93 ± 6.97, 2.22 ± 2.07 mg / dL, respectively) However, no statistically significant difference was found between the low, medium or high level platelet and low or high level lactate groups and the groups with PE (Group-1) and those without PE (Group-2). (p> 0.05; Table-3-4).
Chlorine value was found to be lower in patients with PE (Group-1) compared to patients without PE (Group-2) (94.92 ± 5.38, 99.41 ± 5.15 mmol / L, respectively). A statistically significant difference was found between low, medium or high chlorine groups and PE (Group-1) and PE (Group-2) groups (p <0.05). In addition, patients with low chlorine PE (Group-1) were observed in more patients than the group without PE (Group-2). (Table-5)
Some data on clinical decision rules (CDS) parameters could not be accessed from the patients' files on the hospital information system.
Conclusions:
As a result, we found the diagnostic efficiency of pulmonary CTA required with PE pre-diagnosis to be low (8.6%), consistent with the literature. However, we think that further studies are needed to increase the accuracy and performance of the examination.

Key Words: Emergency Department, Pulmonary embolisms, Computed tomographic pulmonary angiograpy

Kaynakça

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  • 3- Yan Z, Ip IK, Raja AS, Gupta A, Kosowsky JM, Khorasani R. Yield of CT pulmonary angiography in the emercency department when providers override evidence -based clinical decision support. Radiology. 2017;282:717-25.
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  • 6- Swana D, S. Hitchenb, F. A. Klokc, J. Thachil. The problem of under-diagnosis and over-diagnosis of pulmonary embolism. Thrombosis Research. 2019; 177:122-9.
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  • 12- Calder K.K, Herbert M, Henderson S.O. The mortality of untreated pulmonary embolism in emergency department patients . Ann. Emerg Med. 2005;45:302-10.
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  • 14- Centers for Disease Control and Prevention. Quick Stats: Annual percentage of emergency department visits with selected imaging tests ordered or provided — National Hospital Ambulatory Medical Care Survey, United States, 2001–2010.
  • 15- Klang E, Beytelman A, Greenberg D, Or J, Guranda L. Overuse of head CT examinations for the investigation of minor head trauma: analysis of contributing factors. J Am Coll Radiol. 2017; 14:171-6.
  • 16- Pattersoni BW, Pang PS, AlKhawam L, Hamedan, AG, Mendonca EA, Zhao Ying-Qi, Venkatesh AK. The association between use of brain CT for atraumatic headache and 30 –day emergency department revisitation. AJR. 2016; 207: 1-8.
  • 17- Marasco G, Verardi F.M, Eusebi L.H, Guarino S, Romiti A, Vestito A, Bazzoli F, Cavazza M, Zagari R. M. Diagnostic imaging for acute abdominal pain in an emergency department in Italy. İntern Emerg Med. 2019; 14: 1147-53.
  • 18- Raja A.S, Pourjabbar S, İp I.K, Baugh C. W, Sodickson A.D, O’Leary M, Khorasani R. Impact of health information technology-enabled appropriate use criterion on utilization of emergency department CT for renal colic. AJR. 2019; 212:1-4.
  • 19- Shinagare A.B, Ip I.K, Raja A.S, Sahni V.A, Banks P, Khorasani R. Use of CT and MRI in emergency department patients with acute pancreatitis. Abdom İmaging. 2015; 40: 272-7.
  • 20- Coco A.S, O’Gurek D.T. Increased emergency department computed tomography use for common chest symptoms without clear patient benefits. J Am Board Fam Med. 2012; 25:33-41.
  • 21- Lee J, Kirschner J, Pawa S, Wiener DE, Newman DH, Shah K. Computed tomography use in adult emergency department of an academic urban hospital from 2001 to 2007. Ann Emerg Med. 2010;56:591-6.
  • 22- Gupta R.R, Kakarla R.K, Kirshenbaum K.J, Tapson V.F. D-dimers and efficacy of clinical risk estimation algorithms: sensitivity in evaluation of acute pulmonary embolism. AJR Am J Roentgenol. 2009; 193:425-30.
  • 23- Quiroz R, Kucher N, zou KH, et al. Clinical validity of a negative computed tomograhy scan in patients with suspected pulmonary embolism: a systematic review. JAMA. 2005; 293:2012-7
  • 24- Schoepf UJ, Savino G, Lake DR, Ravenel JG, Costello P. Society of Thaoracic Radiology Consensus Statement Symposium: Multislice CT. Part 2. The age of CT pulmonary angiography. J Thorac İmaging. 2005; 20: 273-9.
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  • 30- Osman M, Subeti S.K, Ahmed A, Khan J, Dawood T, Rios-Bedoya Carlos F and Bachuwa G. Computed tomography pulmonary angiography is overused to diagnose pıulmonary embolism in the emergency department of academic community hospital. J Community Hosp Intern Med Perspect. 2018; 8:6-10
  • 31- Crichlow A, Cuker A, Mills A.M. Overuse of computed tomography pulmonary angiography in the evaluation of patients with suspected pulmonary embolism in the emergency department. Acad Emerg Med. 2012;19: 1219-26.
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ACİL SERVİSE BAŞVURAN HASTALARDA PULMONER BT ANJİOGRAFİ TETKİKİNİN TANI VERİMLİLİĞİNİN DEĞERLENDİRİLMESİ

Yıl 2022, Cilt: 8 Sayı: 3, 281 - 290, 01.09.2022
https://doi.org/10.53394/akd.1059369

Öz

ÖZ
Amaç:
Acil servislerde ileri görüntüleme yöntemleri giderek artan oranlarda kullanılmaya başlamıştır. Bu hızlı artış beraberinde; hem söz konusu görüntüleme yöntemlerinin tanı verimliliğinin düşük olması olasılığını; hem de bu metotlara bağlı gelişebilecek olası zararları gündeme getirmiştir. Bu konuda acil servislerde pulmoner emboliden (PE) şüphelenilen hastalarda ileri görüntüleme yöntemlerinden pulmoner bilgisayarlı tomografi anjiografi (pulmoner BTA) kullanımı özellikle ön plana çıkmaktadır.
Akut PE dünya genelinde önemli bir morbidite ve mortalite nedenidir
Biz bu çalışmada Çanakkale Onsekiz Mart Üniversitesi Hastanesi Acil Servisi’ne başvuran ve PE ön tanısı ile pulmoner BTA tetkiki istenen hastalarda pulmoner BTA tetkikinin tanı verimliliğini araştırmayı amaçladık.
Gereç ve Yöntem:
Çalışma, Çanakkale Onsekiz Mart Üniversitesi Klinik Araştırmalar Etik Kurulu’ndan onay alındıktan sonra Ocak 2016 ile Haziran 2018 ayları arasında acil servise başvuran ve PE ön tanısı ile pulmoner BTA tetkiki istenen hastaların radyolojik görüntülerinin ve medikal kayıtlarının retrospektif olarak incelenmesi yöntemiyle yapıldı. Çalışmaya alınan hastaların klinik bilgileri iki acil servis hekimi tarafından, radyolojik görüntüleri iki radyolog tarafından kör bir şekilde incelendi.
Çalışma verileri SPSS 19 paket programı kullanılarak analiz edildi. Sayısal değişkenlerin karşılaştırmasında Mann Whitney U testi kategorik değişkenlerin karşılaştırmasında Ki-Kare testi kullanıldı. İstatistiksel verilerin yorumunda p<0,05 anlamlı olarak kabul edildi.

Bulgular:
Bu çalışmada Ocak 2016- Haziran 2018 ayları arasında acil servise başvuran ve PE ön tanısı ile pulmoner BTA çekilen toplam 233 hasta tespit edildi. Hastaların 11’i artefaktlar nedeniyle pulmoner BTA görüntü kalitesi yetersiz olduğu için çalışma dışında bırakıldılar. Geriye kalan 222 hastaya ait veriler analiz edildi. Hastaların 19’unda (%8,6) PE pozitif (Grup-1); 203 hasta (% 91.4) Pulmoner emboli negatif (Grup-2) olarak saptandı. Ayrıca PE tespit edilmeyen (Grup-2) hastalardan ikisinde (%0.9) herhangi bir patoloji izlenmedi ve normal olarak raporlandı. Her iki grupta da hastaların acil servise en sık nefes darlığı ikinci sıklıkla göğüs ağrısı, şikayetleri ile başvurdukları görüldü.
Hastaların D-Dimer değerleri tüm hastalarda normalin üstünde olmakla beraber; grup-1’de grup-2’ye göre daha yüksek bulundu (Grup-1’de 6.42 ± 8.02 µg/L; grup-2’de 2.38 ± 1.99 µg/L N: <0.5 µg/L); ancak bulgu istatistiksel olarak anlamlı değildi (p> 0.05; Tablo-2)
PE tespit edilen (Grup-1) hastalarda trombosit sayısı ve laktat değeri PE tespit edilmeyen (Grup-2) hastalara göre daha yüksek (sırasıyla 341.71±146.23, 263.72±107.28 hücre/ml; 5.93±6.97, 2.22±2.07 mg/dL ), olmakla birlikte düşük, orta ya da yüksek düzeyde trombosit ve düşük ya da yüksek düzeyde laktat grupları ile PE tespit edilen (Grup-1) ve PE tespit edilmeyen (Grup-2) grupları arasında istatistiksel anlamlı farklılık bulunmadı (p>0.05). (Tablo-3 ve 4)
PE tespit edilen (Grup-1) hastalarda klor değeri PE tespit edilmeyen (Grup-2) hastalara göre daha düşük (sırasıyla 94.92±5.38, 99.41±5.15 mmol/L) bulundu. Düşük, orta ya da yüksek düzeyde klor grupları ile PE tespit edilen (Grup-1) ve PE tespit edilmeyen (Grup-2) grupları arasında istatistiksel anlamlı olarak farklılık elde edildi (p<0.05). PE tespit edilen (Grup-1) hastalarda yüksek düzeyde klor saptanmadı. Ayrıca düşük düzeyde klor PE tespit edilen (Grup-1) hastalarda PE tespit edilmeyen (Grup-2) gruba göre daha fazla hastada izlendi.
Hastaların hastane bilgi sistemi üzerindeki dosyalarından klinik karar kuralları (KKK) parametrelerine ait bazı verilere ulaşılamadı.

Sonuç:
Sonuç olarak, PE ön tanısı ile istenen pulmoner BTA’nın tanısal verimliliğini, literatürle uyumlu olarak düşük (%8.6) bulduk. Ancak tetkikin doğruluğunu ve performansını arttırmak için ileri çalışmalara ihtiyaç olduğunu düşünmekteyiz.

Anahtar Kelimeler: Acil servis, Pulmoner emboli, Pulmoner BT anjiografi

Kaynakça

  • 1- Broder J, Warshauer DM, Increasing utilization of computed tomography in the adult emergency department, 2000-2005. Emerg Radiol. 2006; 13:25-30.
  • 2- Boland GWL, Guimaraes AS, Mueller PR. The radiologist’s conundrum: benefits and costs of increasing CT capacity and utilization. Eur Radiol. 2009;19:9-11.
  • 3- Yan Z, Ip IK, Raja AS, Gupta A, Kosowsky JM, Khorasani R. Yield of CT pulmonary angiography in the emercency department when providers override evidence -based clinical decision support. Radiology. 2017;282:717-25.
  • 4- Frigini LA, Hoxhaj S, Wintermark M, Gibby C, Lenge De Rosen V, Willis MH. R- Scan: CT angiograhic imaging for pulmonary embolism. J Am Coll Radiol. 2017; 14:637-40.
  • 5- Levin D, Seo JB, Kiely DG, Hatabu H, Gefter W, van Beek EJR, Schiebler ML. Triage for suspected acute pulmonary embolism: think before opening pandora’s box. Eur J Radiol. 2015; 84:1202-11.
  • 6- Swana D, S. Hitchenb, F. A. Klokc, J. Thachil. The problem of under-diagnosis and over-diagnosis of pulmonary embolism. Thrombosis Research. 2019; 177:122-9.
  • 7- Ergan B, Ergün R, Çalışkan T, Aydın K, Tokur ME, Savran Y, Koca U, Cömert B, Gökmen N. Mortalty related risk factors in high-risk pulmonary embolism in the ICU. Can Respir J. 2016; 2016:2432808.
  • 8- Knigth M, Kenyon S, Bruclehurst P, Neilson J, Shakespeare J, Kurinczuk JJ (Eds). on behalf of MBRRACEUK, Saving lives, improving mothers’ care –lessons learned to inform future maternty care from the UK and Ireland confidential enquiries into maternal deaths and morbidity 2009-12. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2014
  • 9- Rubinstein I, Murray D, Hoffstein V. Fatal pulmonary emboli in hospitalized patients: an autopsy study. Arch İntern Med. 1988; 148:1425-6.
  • 10- Wells PS, Anderson DR, Rodger M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer. Ann Intern Med. 2001;135:98-107.
  • 11- Stojanovska J, Carlos RC, Kocher KE, Nagaraju A, Guy K, Kelly AM, Chunghtai AR, Kazerooni EA. CT pulmonary angiography: using decision rules in the emergency department. J. Am Coll Radiol. 2015;12:1023-9.
  • 12- Calder K.K, Herbert M, Henderson S.O. The mortality of untreated pulmonary embolism in emergency department patients . Ann. Emerg Med. 2005;45:302-10.
  • 13- Tung M, Sharma R, Hinson J.S, Nothele S, Pannikottu J, Segal J.B. Factors associated with imaging overuse in the emergency department: a systematic review. Am J Emerg Med. 2018 February; 36(2):301-9.
  • 14- Centers for Disease Control and Prevention. Quick Stats: Annual percentage of emergency department visits with selected imaging tests ordered or provided — National Hospital Ambulatory Medical Care Survey, United States, 2001–2010.
  • 15- Klang E, Beytelman A, Greenberg D, Or J, Guranda L. Overuse of head CT examinations for the investigation of minor head trauma: analysis of contributing factors. J Am Coll Radiol. 2017; 14:171-6.
  • 16- Pattersoni BW, Pang PS, AlKhawam L, Hamedan, AG, Mendonca EA, Zhao Ying-Qi, Venkatesh AK. The association between use of brain CT for atraumatic headache and 30 –day emergency department revisitation. AJR. 2016; 207: 1-8.
  • 17- Marasco G, Verardi F.M, Eusebi L.H, Guarino S, Romiti A, Vestito A, Bazzoli F, Cavazza M, Zagari R. M. Diagnostic imaging for acute abdominal pain in an emergency department in Italy. İntern Emerg Med. 2019; 14: 1147-53.
  • 18- Raja A.S, Pourjabbar S, İp I.K, Baugh C. W, Sodickson A.D, O’Leary M, Khorasani R. Impact of health information technology-enabled appropriate use criterion on utilization of emergency department CT for renal colic. AJR. 2019; 212:1-4.
  • 19- Shinagare A.B, Ip I.K, Raja A.S, Sahni V.A, Banks P, Khorasani R. Use of CT and MRI in emergency department patients with acute pancreatitis. Abdom İmaging. 2015; 40: 272-7.
  • 20- Coco A.S, O’Gurek D.T. Increased emergency department computed tomography use for common chest symptoms without clear patient benefits. J Am Board Fam Med. 2012; 25:33-41.
  • 21- Lee J, Kirschner J, Pawa S, Wiener DE, Newman DH, Shah K. Computed tomography use in adult emergency department of an academic urban hospital from 2001 to 2007. Ann Emerg Med. 2010;56:591-6.
  • 22- Gupta R.R, Kakarla R.K, Kirshenbaum K.J, Tapson V.F. D-dimers and efficacy of clinical risk estimation algorithms: sensitivity in evaluation of acute pulmonary embolism. AJR Am J Roentgenol. 2009; 193:425-30.
  • 23- Quiroz R, Kucher N, zou KH, et al. Clinical validity of a negative computed tomograhy scan in patients with suspected pulmonary embolism: a systematic review. JAMA. 2005; 293:2012-7
  • 24- Schoepf UJ, Savino G, Lake DR, Ravenel JG, Costello P. Society of Thaoracic Radiology Consensus Statement Symposium: Multislice CT. Part 2. The age of CT pulmonary angiography. J Thorac İmaging. 2005; 20: 273-9.
  • 25- Schoepf UJ. Diagnosing pulmonary embolism: time to rewrite the textbooks. Int J Cardiovasc İmaging. 2005; 21: 155-63
  • 26- Stein PD, Fowler SE, Goodman LR, et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med. 2006;354 (22):2317–27.
  • 27- Torbcki A, Perrier A, Konstantinides S, Agnelli G, Galie N, Pruszczyk P, Bengel F, Brady AJB, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP. Guidelines on the diagnosis and management of acute pulmonary embolism. Rev Esp Cardiol. 2008; 61:1330.
  • 28- Penaloza A, Melot C, Motte S. Comparison of the Wells score with the simplified revised Geneva score for assessing pretest probability of pulmonary embolism. Thrombosis Research. 2011; 127: 81-4.
  • 29- Yap KS, Kalff V, Turlakow A, Kelly MJ. A prospective reassessment of the utility of the Wells score in identifying pulmonary embolism. Med J Aust. 2007; 187: 333-6.
  • 30- Osman M, Subeti S.K, Ahmed A, Khan J, Dawood T, Rios-Bedoya Carlos F and Bachuwa G. Computed tomography pulmonary angiography is overused to diagnose pıulmonary embolism in the emergency department of academic community hospital. J Community Hosp Intern Med Perspect. 2018; 8:6-10
  • 31- Crichlow A, Cuker A, Mills A.M. Overuse of computed tomography pulmonary angiography in the evaluation of patients with suspected pulmonary embolism in the emergency department. Acad Emerg Med. 2012;19: 1219-26.
  • 32- Kalb B, Sharma P, Tigges S, Ray G.L, Kitaljima H. D, Costello J. R, Chen Z, Martin D.R. MR imaging of pulmonary embolisim: diagnostic accuracy of contrast – enhanged low- flip angle 3d gre, and nonenhanced free-induction fısp sequences. Radiology. 2012; 263:271-8.
  • 33- Costantino M.M, Randall G, Gosselin M, Brandt M, Spinning K, Vegas C.D. CT angiography in the evaluation of acute pulmonary embolus. AJR. 2008;191: 471-4.
  • 34- Prevedello L.M, Raja A.S, Ip I.K, Sodichson A, Khorasani R. Does clinical decision support reduce unwarranted variation in yield of CT pulmonary angiogram? Am J Med. 2013; 126: 975-81.
  • 35- Drescher F.S, Chandrika S, Weir I.D, Weintraub J. T, Berman L, Lee R, Van Buskirk P.D, Wang Y, Adewunmi A, Fine J.M. Effectiveness and acceptibility of a computerized decision support system using modified wells criteria for evaluation of suspected pulmonary embolism. Ann Emerg Med. 2011; 57:613-21.
  • 36- Raja A.S, Ip I.K, Prevedello L.M, Sodichson A, Farkas C, Zane R.D, Hanson R, Goldhaber S.Z, Gill R.R, Khorasani R. Effect of computerized clinical decision support on the use and yield of CT pulmonary angiography in the emergency department. Radiology. 2012; 262:468-74.
  • 37- Dunne R.M, Ip I.K, Abbett S, Gershanik E.F, Raja A.S, Hunsaker A, Khorasani R. Effect of evidence-based clinical decision support on the use and yield of ct pulmonary angiographic imaging in hospitalized patients. Radiology. 2015; 276:167-74.
  • 38- Battal B, Karaman B, Gümüş S, Akgün V, Bozlar U, Taşar M. Pulmoner emboli şüphesi bulunan hastaların çok kesitli BT pulmoner anjiyografi incelemelerinde karşılaşılan tromboemboli dışı bulguların analizi. Türkiye Acil Tıp Dergisi- Turk J Emerg Med. 2011; 11:13-9.
  • 39- Wood K.E. Major pulmonary embolism review of a pathopysiologic approach to the golden hour of hemodynamically significant pulmonary embolisim. CHEST. 2002;121:877-905.
  • 40- Kline J. A, Courtney D.M, Beam D.M, King M.C, Steuerwald M. Incidence and predictors of repeated computed tomographic pulmonary angiogarphy in emergency department patients. Annals of Emergency Medicine. 2008; 54:41-8.
  • 41- Goldhaber SZ, Bounameaux H. Pulmonary embolism and deep vein thrombosis. Lancet. 2012; 379: 1835-46.
  • 42- Kucher N, Rossi E, De Rosa M, Goldhaber SZ. Massive pulmonary embolism. Circulation. 2006; 113: 577-82.
  • 43- Belohlavek J, Dytrych V, Linhart A. Pulmonary embolism, part I: epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism. Exp Clin Cardiol. 2013; 18: 129-38.
  • 44- Monreala M, Lafoza E, Ruizb J, Gimeneza G. Platelet count in acute pulmonary embolism: its relationship to recurrences. Haemostasis. 1993; 23: 263-8.
  • 45- Kraut JA, Madias NE. Lactic acidosis. N Engl J Med. 2014; 371: 2309-19.
  • 46- Vanni S, Viviani G, Baioni B, Pepe G, Nazerian P, Socci F, Bartolucci M, Bartolini M, Grifoni S. Prognostic value of plasma lactate levels among patients with pulmonary embolism: the thrombo-embolism lactate outcome study. Ann Emerg Med. 2013; 61: 330-8.
  • 47- Vanni S, Jimenez D, Nazerian P, morello Fulvino, Parisi M, Daghini E, Pratesi M, Lopez R, Bedate P, Lobo JL, Jara-Palomares L, Portillo AK, Grifoni S. Short-term clinical outcome of normotensive patients with acute PE and high plasma lactate. Thorax. 2015; 70: 333-8.
  • 48- Prins KW, Kalra R, Rose L, Assad TR, Archer SL, Bajaj NS, Weir EK, Prisco SZ, Pritzker M, Lutsey PL, Brittain E, Theneppan T. Hypochloremia is a noninvasive predictor of mortality in pulmonary arterial hypertension. J Am Heart Assoc. 2020; 9: 1-10.
Toplam 48 adet kaynakça vardır.

Ayrıntılar

Birincil Dil Türkçe
Konular Klinik Tıp Bilimleri
Bölüm Araştırma Makalesi
Yazarlar

Şenay Bengin Ertem 0000-0002-7237-6061

Nilüfer Aylanç Bu kişi benim 0000-0002-5889-9763

Murat Daş Bu kişi benim 0000-0003-0893-6084

Okan Bardakçı Bu kişi benim 0000-0001-6829-7435

Yayımlanma Tarihi 1 Eylül 2022
Gönderilme Tarihi 29 Ocak 2021
Yayımlandığı Sayı Yıl 2022 Cilt: 8 Sayı: 3

Kaynak Göster

APA Ertem, Ş. B., Aylanç, N., Daş, M., Bardakçı, O. (2022). ACİL SERVİSE BAŞVURAN HASTALARDA PULMONER BT ANJİOGRAFİ TETKİKİNİN TANI VERİMLİLİĞİNİN DEĞERLENDİRİLMESİ. Akdeniz Tıp Dergisi, 8(3), 281-290. https://doi.org/10.53394/akd.1059369