有藥師參與的團隊照護對於血壓控制有較佳結果
有藥師參與的團隊照護對於血壓控制有較佳結果
作者：Fran Lowry
出處：WebMD醫學新聞
November 23, 2009 — 根據發表於11月23日內科醫學誌的研究結果，急診室使用胸部電腦斷層血管攝影(computed tomography angiograms，CTAs)評估急性肺栓塞病患，意外發現肺結節或腺病的機會是發現肺栓塞的兩倍以上。
北卡羅來納大學的William B. Hall醫師等人寫道，胸部電腦斷層掃描上的小肺結節可能代表支氣管肺癌；不過，這些病灶大多可能為良性。意外發現有肺結節可能會造成病患極大的焦慮，通常需要追蹤多次X光檢查以及其他診斷方式。
這項研究的目標是評估此類意外發現時的盛行率和處置的運用。
研究者回顧在一間每年有50,000人次就診之大型教學3級照護醫院急診室589例肺部電腦斷層血管攝影的結果；病患的平均年紀為53歲(範圍：34 – 72 歲)，63%是女性。
研究者報告指出，有55例CTAs (9%)發現肺栓塞，195名病患(33%)則是發現其他的診斷。
總共有141名病患(24%)是新的意外發現，需要臨床或X光追蹤。肺結節是最常見的意外發現，總共發現127名病患(22%)，其中73人是新發現。
作者們指出，使用目前的臨床指引，96%新意外發現的肺結節病患可以建議使用追蹤電腦斷層或其他方式。此外，有51名病患(9%)的新腺病需要追蹤。
作者們指出，此研究的主要限制是，只在一個3級照護中心進行，因此結果無法一般化到其他機構。另一個限制則是，回溯型研究設計可能在病患取樣上有偏差。
他們結論表示，在急診室評估急性肺栓塞時，建議使用CTA這種全面性方法，以確認臨床風險和獲得較多診斷。
作者們指出，一線照護醫師應更熟悉建議用來評估肺結節的方法，因為增加急診使用CTA可以發現更多這些病灶。
以色列Kaplan醫學中心的Ami Schattner醫師在編輯評論中形容此研究為一個重要研究。
他寫道，這些發現強調，這些意外的無症狀發現，數量是肺栓塞的2.5倍，這足以讓我們審慎評估大量使用CTA於肺栓塞的相關問題。
這些問題包括進行CTA時的放射線和顯影劑曝露；異常腎功能和對顯影劑過敏會造成這類病患的手術風險；另外，婦女、年輕病患、重複檢查的患者需考量X光射線風險。
Schattner醫師寫道，許多有症狀的肺部或胸腔疾病患者是以CTA發現，這似乎是支持此項檢測的強力理由，不過，Hall醫師等人報告的資料強烈認為，多數病患有共同狀況，呼吸困難或胸痛等不同診斷，可以用臨床方法和簡單的輔助試驗，如品質良好的(不是攜帶型的)胸部X光機和心電圖。
Schattner醫師結論表示，CTA應保留給住院病患或換氣/灌注掃描結果不確定、胸部X光有異常發現、結果不一致、有類似主動脈剝離之不尋常發現的病患。
他寫道，掃描技術預期會有進步，例如單光子放射[CT換氣/灌注] 閃爍造影術，可以進一步減少非診斷檢查的研究，幫助將情況恢復到肺栓塞疑似案例的評估用途上。
Hall醫師和 Schattner醫師皆宣告沒有相關財務關係。
Chest CT Angiograms to Diagnose Pulmonary Embolism Twice as Likely to Find Other Pathology
By Fran Lowry
Medscape Medical News
November 23, 2009 — Chest computed tomography angiograms (CTAs) to evaluate patients for acute pulmonary embolism in the emergency department are more than twice as likely to find an incidental pulmonary nodule or adenopathy as they are to find a pulmonary embolism, according to the results of new research published in the November 23 issue of the Archives of Internal Medicine.
"Small pulmonary nodules on chest CT scans could indicate bronchogenic carcinoma; however, these lesions are much more likely to be benign," William B. Hall, MD, from the University of North Carolina at Chapel Hill, and colleagues write. "Incidental findings of pulmonary nodules can be a source of great anxiety for patients and often generate multiple follow-up radiographic studies and other diagnostic interventions."
The aim of this study was to determine the prevalence and management implications of such incidental findings.
The investigators reviewed the results of 589 pulmonary CTAs that were ordered in the emergency department of a large academic tertiary care hospital that had 50,000 visits annually.
The mean age of the patients was 53 years (range, 34 – 72 years), and 63% were women.
The investigators report that pulmonary embolism was found in 55 CTAs (9%) and that 195 patients (33%) had findings indicative of other diagnoses.
A total of 141 patients (24%) had a new incidental finding that required clinical or radiologic follow-up.
Pulmonary nodules were the most common incidental finding and were found in 127 patients (22%). Of these, 73 were a new finding.
"Using current clinical guidelines, follow-up [CT] or another procedure would be recommended for 96% of patients with new incidental pulmonary nodules," the authors note.
In addition, new adenopathy requiring follow-up was found in 51 patients (9%).
The authors note that the primary limitation of their study is that it was carried out at a single tertiary care center, and therefore results may not be generalizable to other settings. The retrospective study design, which could have introduced bias in patient selection, is another limitation.
They conclude that systematic approaches to determining clinical risk and higher yield indications for CTA are recommended during assessments of acute pulmonary symptoms in the emergency department.
"Primary care physicians should become familiar with recommended approaches for evaluation of pulmonary nodules," the authors add, "because increasing use of CTA in the acute setting will lead to the discovery of a large number of these lesions."
In an accompanying editorial, Ami Schattner, MD, from Kaplan Medical Center, Rehovot, Israel, called this an important study.
"These findings highlight the abundance of incidental asymptomatic findings, outnumbering [pulmonary embolism] by a factor of 2.5, and may prompt us to critically examine some of the problems associated with the proliferating use of CTA in [pulmonary embolism]," he writes.
These problems include exposure to radiation and contrast during CTA. Abnormal renal function and allergy to contrast material make the procedure risky for patients with these conditions, and the radiation risk is considerable, particularly in women, younger patients, and all patients who have repeated examinations.
"The many patients in whom a symptomatic pulmonary or thoracic disease is revealed by the CTA may seem a compelling reason to support the test," Dr. Schattner writes. "However, the data reported by Hall et al strongly suggest that most of the patients have common conditions, and the differential diagnosis of dyspnea or chest pain can be made by clinical methods and simple ancillary tests such as a good-quality (e.g., not portable) chest radiography and electrocardiography."
Dr. Schattner concludes that CTA should be reserved for inpatients or patients with indeterminate findings on ventilation/perfusion scans, abnormal findings on chest radiography, discordant findings, or unusual presentations such as those compatible also with aortic dissection.
"Expected advances in scanning techniques such as single photon emission [CT ventilation/perfusion] scintigraphy are likely to further reduce the number of nondiagnostic studies and help swing the pendulum back to a more balanced evaluation of suspected cases of [pulmonary embolism]," he writes.
Dr. Hall and Dr. Schattner have disclosed no relevant financial relationships.
Arch Intern Med. 2009;169(21):1966–1968, 1961–1965.
