Javier Galipienzo

MD Anderson Cancer Center Madrid

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Frederikus A. Klok

Leiden University Medical Center

Nick van Es

University of Amsterdam

Menno V. Huisman

Leiden University Medical Center

Harry R. Büller

Amsterdam University Medical Centers

Noémie Kraaijpoel

University of Amsterdam

Pierre‐Marie Roy

Inserm

Toshihiko Takada

Fukushima Medical University

Marc Righini

University Hospital of Geneva

Grégoire Le Gal

Ottawa Hospital

Geert‐Jan Geersing

University Medical Center Utrecht

Cooperative Institutions

MD Anderson Cancer Center Madrid

Leiden University Medical Center

University Medical Center Utrecht

Amsterdam University Medical Centers

Academic Medical Center

Hospital Universitario Príncipe de Asturias

Utrecht University

University of Amsterdam

Inserm

Leiden University

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Accuracy of physicians’ intuitive risk estimation in the diagnostic management of pulmonary embolism: an individual patient data meta-analysis

Journal of Thrombosis and Haemostasis (2023)

Rosanne van Maanen Emily S.L. Martens Toshihiko Takada Pierre‐Marie Roy Kerstin de Wit

In patients clinically suspected of having pulmonary embolism (PE), physicians often rely on intuitive estimation ("gestalt") of PE presence. Although shown to be predictive, gestalt is criticized for its assumed variation across physicians and lack of standardization.To assess the diagnostic accuracy of gestalt in the diagnosis of PE and gain insight into its possible variation.We performed an individual patient data meta-analysis including patients suspected of having PE. The primary outcome was diagnostic accuracy of gestalt for the diagnosis of PE, quantified as risk ratio (RR) between gestalt and PE based on 2-stage random-effect log-binomial meta-analysis regression as well as gestalts' sensitivity and specificity. The variability of these measures was explored across different health care settings, publication period, PE prevalence, patient subgroups (sex, heart failure, chronic lung disease, and items of the Wells score other than gestalt), and age.We analyzed 20 770 patients suspected of having PE from 16 original studies. The prevalence of PE in patients with and without a positive gestalt was 28.8% vs 9.1%, respectively. The overall RR was 3.02 (95% CI, 2.35-3.87), and the overall sensitivity and specificity were 74% (95% CI, 68%-79%) and 61% (95% CI, 53%-68%), respectively. Although variation was observed across individual studies (I2, 90.63%), the diagnostic accuracy was consistent across all subgroups and health care settings.A positive gestalt was associated with a 3-fold increased risk of PE in suspected patients. Although variation was observed across studies, the RR of gestalt was similar across prespecified subgroups and health care settings, exemplifying its diagnostic value for all patients suspected of having PE.

10.1016/j.jtha.2023.05.023

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Citations (3)

Perioperative management of non-deferrable oncologic surgeries during COVID-19 pandemic in Madrid, Spain. Is it safe?

Revista Española de Anestesiología y Reanimación (English Edition) (2022)

Javier Galipienzo R.J. Otta-Oshiro Débora Berdecio Salvatierra Cristina Laura Casado Medrano Irene López Rojo

Pandemic

Isolation

10.1016/j.redare.2021.03.005

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Citations (1)

Safety and Efficiency of Diagnostic Strategies for Ruling Out Pulmonary Embolism in Clinically Relevant Patient Subgroups : A Systematic Review and Individual-Patient Data Meta-analysis.

Annals of Internal Medicine (2022)

Milou A.M. Stals Toshihiko Takada Noémie Kraaijpoel Nick van Es Harry R. Büller

How diagnostic strategies for suspected pulmonary embolism (PE) perform in relevant patient subgroups defined by sex, age, cancer, and previous venous thromboembolism (VTE) is unknown.To evaluate the safety and efficiency of the Wells and revised Geneva scores combined with fixed and adapted D-dimer thresholds, as well as the YEARS algorithm, for ruling out acute PE in these subgroups.MEDLINE from 1 January 1995 until 1 January 2021.16 studies assessing at least 1 diagnostic strategy.Individual-patient data from 20 553 patients.Safety was defined as the diagnostic failure rate (the predicted 3-month VTE incidence after exclusion of PE without imaging at baseline). Efficiency was defined as the proportion of individuals classified by the strategy as "PE considered excluded" without imaging tests. Across all strategies, efficiency was highest in patients younger than 40 years (47% to 68%) and lowest in patients aged 80 years or older (6.0% to 23%) or patients with cancer (9.6% to 26%). However, efficiency improved considerably in these subgroups when pretest probability-dependent D-dimer thresholds were applied. Predicted failure rates were highest for strategies with adapted D-dimer thresholds, with failure rates varying between 2% and 4% in the predefined patient subgroups.Between-study differences in scoring predictor items and D-dimer assays, as well as the presence of differential verification bias, in particular for classifying fatal events and subsegmental PE cases, all of which may have led to an overestimation of the predicted failure rates of adapted D-dimer thresholds.Overall, all strategies showed acceptable safety, with pretest probability-dependent D-dimer thresholds having not only the highest efficiency but also the highest predicted failure rate. From an efficiency perspective, this individual-patient data meta-analysis supports application of adapted D-dimer thresholds.Dutch Research Council. (PROSPERO: CRD42018089366).

D-dimer

10.7326/m21-2625

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Citations (48)

On multislice computed tomography pulmonary angiography and ventilation/perfusion scanning for the diagnostic work-up of suspected pulmonary embolism

European Journal of Internal Medicine (2010)

Javier Galipienzo Julio Flores Jaime García de Tena

Pulmonary angiography

Multislice computed tomography

Multislice

Pulmonary vasculature

10.1016/j.ejim.2010.09.009

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Citations (0)

Effectiveness of a diagnostic algorithm combining clinical probability, D-dimer testing, and computed tomography in patients with suspected pulmonary embolism in an emergency department.

PubMed (2013)

Javier Galipienzo Jaime García de Tena Joan Ericka Flores C. Álvarez Angel Garciá‐Avello

The aim of our study was to assess the clinical effectiveness of a simplified algorithm using the Wells clinical decision rule, D-dimer testing, and computed tomography (CT) in patients with suspected pulmonary embolism (PE) in an Emergency Department (ED).Patients with clinically suspected PE from the Emergency Department were included from May 2007 through December 2008. Clinical probability was assessed using the Wells clinical decision rule and a VIDAS D-dimer assay was used to measure D-dimer concentration. Patients were categorized as "pulmonary embolism unlikely" or "pulmonary embolism likely" using the dichotomized version of the Wells clinical decision rule. Pulmonary embolism was considered excluded in patients with unlikely probability and normal D-dimer test (< 500 ng/ml). All other patients underwent CT, and pulmonary embolism was considered present or excluded based on the results. Anticoagulants were withheld from patients classified as excluded, and all patients were followed up for 3 months.241 patients were included in the study. The prevalence of PE in the entire population was 23.6%. The combination of unlikely probability using the dichotomized Wells clinical decision rule and a normal D-dimer level occurred in 23.6%, thus making CT unnecessary. During the followup period, no thromboembolic events were recorded and there were no deaths related to venous thromboembolic disease (3-month thromboembolic risk 0% [95% CI, 0%-8%]).In this study we have confirmed the effectiveness of a diagnostic management strategy using a simple clinical decision rule, D-dimer testing, and CT in the evaluation and management of patients with clinically suspected pulmonary embolism.

D-dimer

Clinical prediction rule

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Is stand‐alone D‐dimer testing safe to rule out acute pulmonary embolism?

Journal of Thrombosis and Haemostasis (2016)

Nick van Es Tom van der Hulle Harry R. Büller Frederikus A. Klok Menno V. Huisman

D-dimer

Post hoc

Post-hoc analysis

10.1111/jth.13574

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Citations (17)

Ruling out pulmonary embolism across different healthcare settings: A systematic review and individual patient data meta-analysis

PLoS Medicine (2022)

Geert‐Jan Geersing Toshihiko Takada Frederikus A. Klok Harry R. Büller D. Mark Courtney

The challenging clinical dilemma of detecting pulmonary embolism (PE) in suspected patients is encountered in a variety of healthcare settings. We hypothesized that the optimal diagnostic approach to detect these patients in terms of safety and efficiency depends on underlying PE prevalence, case mix, and physician experience, overall reflected by the type of setting where patients are initially assessed. The objective of this study was to assess the capability of ruling out PE by available diagnostic strategies across all possible settings.We performed a literature search (MEDLINE) followed by an individual patient data (IPD) meta-analysis (MA; 23 studies), including patients from self-referral emergency care (n = 12,612), primary healthcare clinics (n = 3,174), referred secondary care (n = 17,052), and hospitalized or nursing home patients (n = 2,410). Multilevel logistic regression was performed to evaluate diagnostic performance of the Wells and revised Geneva rules, both using fixed and adapted D-dimer thresholds to age or pretest probability (PTP), for the YEARS algorithm and for the Pulmonary Embolism Rule-out Criteria (PERC). All strategies were tested separately in each healthcare setting. Following studies done in this field, the primary diagnostic metrices estimated from the models were the "failure rate" of each strategy-i.e., the proportion of missed PE among patients categorized as "PE excluded" and "efficiency"-defined as the proportion of patients categorized as "PE excluded" among all patients. In self-referral emergency care, the PERC algorithm excludes PE in 21% of suspected patients at a failure rate of 1.12% (95% confidence interval [CI] 0.74 to 1.70), whereas this increases to 6.01% (4.09 to 8.75) in referred patients to secondary care at an efficiency of 10%. In patients from primary healthcare and those referred to secondary care, strategies adjusting D-dimer to PTP are the most efficient (range: 43% to 62%) at a failure rate ranging between 0.25% and 3.06%, with higher failure rates observed in patients referred to secondary care. For this latter setting, strategies adjusting D-dimer to age are associated with a lower failure rate ranging between 0.65% and 0.81%, yet are also less efficient (range: 33% and 35%). For all strategies, failure rates are highest in hospitalized or nursing home patients, ranging between 1.68% and 5.13%, at an efficiency ranging between 15% and 30%. The main limitation of the primary analyses was that the diagnostic performance of each strategy was compared in different sets of studies since the availability of items used in each diagnostic strategy differed across included studies; however, sensitivity analyses suggested that the findings were robust.The capability of safely and efficiently ruling out PE of available diagnostic strategies differs for different healthcare settings. The findings of this IPD MA help in determining the optimum diagnostic strategies for ruling out PE per healthcare setting, balancing the trade-off between failure rate and efficiency of each strategy.

10.1371/journal.pmed.1003905

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Citations (31)

Air embolism after deflation of the pneumoperitoneum in fast-track laparoscopic assisted hemicolectomy

Chinese Medical Journal (2013)

Javier Galipienzo Rogelio Rosado Beatriz Zarza J. Olarra

To the editor: Post-deflation air embolism (AE) is an infrequent and rarely published manifestation in laparoscopic surgery, its pathophysiological mechanisms being barely understood. We present a case of AE during a fast-track laparoscopic hemicolectomy. Male, 58 years old, scheduled for a left hemicolectomy after being diagnosed a tumour in the colon. Before induction, vital signs were normal: AP of 110/80 mmHg (1 mmHg =0.133 kPa), and cardiac frequency (CF) of 76 beats/min. The patient was induced with 2 mg/kg of fentanyl, and 0.15 mg/kg of cisatracure and propofol via TCI infusion to maintain hypnosis. Analgesia was maintained through epidural perfusion of L-bupivacaine 0.25%. We began with the laparoscopic assisted procedure but by technical difficulties we decided to conduct a laparotomy. Once the laparotomy, incidental appendectomy and mobilization of the left colon and splenic flexure was performed. At this very moment, the patient's SpO2 levels plummeted to 79%, while ETCO2 ones dropped to 20 mmHg. Tachycardia (130 beats/min), and arterial hypotension (60/40) occurred. There was no response to fluids therapy. Spasm of the bronchus and pressure pneumothorax were ruled out as causes of the episode. We initiated treatment with noradrenaline. In view of a possible pulmonary thromboembolism, or an AE, the surgical procedure was suspended. Thoracic and lower limbic computerized tomographies (CT) were carried out, ruling out pulmonary embolism and deep venous thrombosis. Transthoracic ECO cardiogram was normal. Intra-operatory AE was diagnosed by exclusion. AE is a rare complication, its current incidence being unknown.1 Causes are varied, the most frequent ones being gravitational ones, amongst which are head and neck interventions, and laparoscopic assisted surgery.2 Pathophysiologic interpretation of symptomatic AEs in laparoscopic surgery must be carried out according to the moment they are manifested. If it takes place at the onset of the laparoscopic procedure, it is usually a brusque and serious episode after the undetected puncture of a blood vessel. Sudden injection of CO2 into the blood stream produces an important hemodynamic collapse, including acute rise and subsequent fall of PetCO2 and of cardiac output, as well as serious cardiorespiratory insufficiency. On the other hand, AE can also occur during the maintenance phase. Most probably, the entry of gas takes place throughout the procedure as a consequence of varying pressure levels between the pneumoperitoneum and the intravascular space. Lastly, it may happen, just as we believe it happened in our case, that the AE occurs once the pneumoperitoneum has already been released, either immediately or more or less deferred. It's a rarely published occurrence,3 and one which we generally don't often think of. Researchers have arrived at the conclusion that part of the CO2 intravascular injection may get stuck in the splenic region, only to be released with decompression of the peritoneum and or mobilisation of the patient.4 Another theory, suggests that it could be caused by physical phenomena with no vascular injury involved. A state of blood “stagnation” in the splenic region, together with CO2 saturation may lead to a releasing of CO2 bubbles with any sudden decrease in pressure.5 If these bubbles reach a considerable volume, and enter the systemic venous system, an iatrogenic AE may occur (a situation similar to decompression syndrome in scuba divers). Either of these two circumstances could have taken place in our patient. We must be aware of the possibility of AE occurring once the pneumoperitoneum has been released. Javier Galipienzo Rogelio Rosado Beatriz Zarza Jose Olarra Servicio de Anestesiología y Reanimación. Hospital Universitario de Fuenlabrada. Fuenlabrada. Madrid. Spain (Galipienzo J, Rosado R and Olarra J) Hospital Universitario Ramón y Cajal. Madrid. Spain (Zarza B) Correspondence to: Javier Galipienzo. Servicio de Anestesiologíay Reanimación. Hospital Universitario de Fuenlabrada. C/ Camino del Molino s.n. 28942. Fuenlabrada, Madrid, Spain (Email: [email protected])

Hemicolectomy

10.3760/cma.j.issn.0366-6999.20130762

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Citations (1)

Safety and Efficiency of Diagnostic Strategies for Ruling Out Pulmonary Embolism in Clinically Relevant Patient Subgroups

Annals of Internal Medicine (2021)

Milou A.M. Stals Toshihiko Takada Noémie Kraaijpoel Nick van Es Harry R. Büller

Background: How diagnostic strategies for suspected pulmonary embolism (PE) perform in relevant patient subgroups defined by sex, age, cancer, and previous venous thromboembolism (VTE) is unknown. Purpose: To evaluate the safety and efficiency of the Wells and revised Geneva scores combined with fixed and adapted D-dimer thresholds, as well as the YEARS algorithm, for ruling out acute PE in these subgroups. Data Sources: MEDLINE from 1 January 1995 until 1 January 2021. Study Selection: 16 studies assessing at least 1 diagnostic strategy. Data Extraction: Individual-patient data from 20 553 patients. Data Synthesis: Safety was defined as the diagnostic failure rate (the predicted 3-month VTE incidence after exclusion of PE without imaging at baseline). Efficiency was defined as the proportion of individuals classified by the strategy as "PE considered excluded" without imaging tests. Across all strategies, efficiency was highest in patients younger than 40 years (47% to 68%) and lowest in patients aged 80 years or older (6.0% to 23%) or patients with cancer (9.6% to 26%). However, efficiency improved considerably in these subgroups when pretest probability–dependent D-dimer thresholds were applied. Predicted failure rates were highest for strategies with adapted D-dimer thresholds, with failure rates varying between 2% and 4% in the predefined patient subgroups. Limitations: Between-study differences in scoring predictor items and D-dimer assays, as well as the presence of differential verification bias, in particular for classifying fatal events and subsegmental PE cases, all of which may have led to an overestimation of the predicted failure rates of adapted D-dimer thresholds. Conclusion: Overall, all strategies showed acceptable safety, with pretest probability–dependent D-dimer thresholds having not only the highest efficiency but also the highest predicted failure rate. From an efficiency perspective, this individual-patient data meta-analysis supports application of adapted D-dimer thresholds. Primary Funding Source: Dutch Research Council. (PROSPERO: CRD42018089366)

D-dimer

10.7326/m21-2625

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Citations (23)

COVID-19: gynecologic cancer surgery at a single center in Madrid

International Journal of Gynecological Cancer (2020)

Javier De Santiago Carmen Yelo María F Chereguini Ana Roel Conde Javier Galipienzo

Objectives While numerous medical facilities have been forced to suspend oncological surgery due to system overload, debate has emerged on using non-surgical options on cancer cases during the pandemic. The goal of our study was to analyze, in a retrospective cohort study, the results of gynecological cancer surgery and evaluate postoperative complications in a single center in one of the most affected areas in Europe. Methods We retrospectively analyzed the records of patients who were referred between March 2020 and May 2020 for primary surgical treatment of breast, endometrial, ovarian, cervical, or vulvar cancer. Results The study included a total of 126 patients. Median age was 60 years (range 29–89). Patients were referred with breast (76/126, 60.3%), endometrial (29/126, 23%), ovarian (14/126, 11.1%), cervical (5/126, 4%), or vulvar cancer (2/126, 1.6%). Polymerase chain reaction (PCR) test for detection of severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) was only conducted in 50% of cases due to the low availability of tests during the first phase of our study, and was indicated only in suspected cases according to the healthcare authorities' protocol. Median hospital stay was 1 day (range 0–18). Excluding breast surgery, laparoscopy was the most used procedure (43/126, 34.1%). 15 patients had a postoperative complication (15/126, 11.9%); only in 2 patients (2/15 13.3%) were there reports of Clavien–Dindo grade 3 or 4 complications. 6 patients tested positive for COVID-19 following a PCR diagnostic test, and these surgeries were cancelled. Conclusions Adequate protective measures in the setting of COVID-19 free institutions enabled the continuity of cancer surgery without significant compromise of the safety of patients or healthcare workers.

10.1136/ijgc-2020-001638

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Citations (17)