Diagnostic management of acute pulmonary embolism: a prediction model based on a patient data meta-analysis.

AIMS: Risk stratification is used for decisions regarding need for imaging in patients with clinically suspected acute pulmonary embolism (PE). The aim was to develop a clinical prediction model that provides an individualized, accurate probability estimate for the presence of acute PE in patients with suspected disease based on readily available clinical items and D-dimer concentrations. METHODS AND RESULTS: An individual patient data meta-analysis was performed based on sixteen cross-sectional or prospective studies with data from 28 305 adult patients with clinically suspected PE from various clinical settings, including primary care, emergency care, hospitalized and nursing home patients. A multilevel logistic regression model was built and validated including ten a priori defined objective candidate predictors to predict objectively confirmed PE at baseline or venous thromboembolism (VTE) during follow-up of 30 to 90 days. Multiple imputation was used for missing data. Backward elimination was performed with a P-value <0.10. Discrimination (c-statistic with 95% confidence intervals [CI] and prediction intervals [PI]) and calibration (outcome:expected [O:E] ratio and calibration plot) were evaluated based on internal-external cross-validation. The accuracy of the model was subsequently compared with algorithms based on the Wells score and D-dimer testing. The final model included age (in years), sex, previous VTE, recent surgery or immobilization, haemoptysis, cancer, clinical signs of deep vein thrombosis, inpatient status, D-dimer (in µg/L), and an interaction term between age and D-dimer. The pooled c-statistic was 0.87 (95% CI, 0.85-0.89; 95% PI, 0.77-0.93) and overall calibration was very good (pooled O:E ratio, 0.99; 95% CI, 0.87-1.14; 95% PI, 0.55-1.79). The model slightly overestimated VTE probability in the lower range of estimated probabilities. Discrimination of the current model in the validation data sets was better than that of the Wells score combined with a D-dimer threshold based on age (c-statistic 0.73; 95% CI, 0.70-0.75) or structured clinical pretest probability (c-statistic 0.79; 95% CI, 0.76-0.81). CONCLUSION: The present model provides an absolute, individualized probability of PE presence in a broad population of patients with suspected PE, with very good discrimination and calibration. Its clinical utility needs to be evaluated in a prospective management or impact study. REGISTRATION: PROSPERO ID 89366.

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.

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).

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

BACKGROUND: 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. METHODS AND FINDINGS: 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. CONCLUSIONS: 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.

[Buyers' club†: an alternative for access to treatment†?] / Buyers' club†: une alternative pour l'accès au traitement†?

Rapid medication management for patients infected with HIV, HCV or HBV is key in optimizing a more favourable clinical response, in terms of morbidity, mortality, quality-of-life and reduced risk of transmission. If a drug is expensive, access to treatment for an uninsured patient with limited resources can be a hurdle that leads to forgoing healthcare for economic reasons. The buyers' club's objective is to provide logistics and/or financial assistance to a patient aiming to import qualitative generics for his personal use at an affordable price oversea. The drug is purchased on the internet.

La prise en charge médicamenteuse rapide pour les patients infectés par le VIH, le VHC ou le VHB est un élément clé pour obtenir une réponse clinique favorable en termes de morbidité, mortalité, et qualité de vie, et elle permet de diminuer les risques de transmission. Lorsqu'un médicament est cher, l'accès aux traitements pour un·e patient·e sans assurance avec des ressources limitées est une barrière qui peut conduire à renoncer aux soins pour des raisons économiques. Un buyers' club est une structure dont l'objectif est d'apporter une aide logistique et/ou financière à un·e patient·e qui souhaite importer à titre personnel un médicament de qualité et efficace à des conditions économiquement plus favorables. L'achat du médicament se fait par internet.

Cost-effectiveness of HLA-DQB1/HLA-B pharmacogenetic-guided treatment and blood monitoring in US patients taking clozapine.

Less than 1% of adult patients with schizophrenia taking clozapine develop agranulocytosis, and most of these cases occur within the first weeks of treatment. The human leukocyte antigen (HLA) region has been associated with genetic susceptibility to clozapine-induced agranulocytosis (single amino acid changes in HLA-DQB1 (126Q) and HLA-B (158T)). The current study aimed to evaluate the cost-effectiveness, from a healthcare provider's perspective, of an HLA genotype-guided approach in patients with treatment-resistant schizophrenia who were taking clozapine and to compare the results with the current absolute neutrophil count monitoring (ANCM) schemes used in the USA. A semi-Markovian model was developed to simulate the progress of a cohort of adult men and women who received clozapine as a third-line antipsychotic medication. We compared current practices using two genotype-guided strategies: (1) HLA genotyping followed by clozapine, with ANCM only for patients who tested positive for one or both alleles (genotype-guided blood sampling); (2) HLA genotyping followed by clozapine for low-risk patients and alternative antipsychotics for patients who tested positive (clozapine substitution scheme). Up to a decision threshold of $3.9 million per quality-adjusted life-year (90-fold the US gross domestic product per capita), the base-case results indicate that compared with current ANCM, genotype-guided blood sampling prior to clozapine initiation appeared cost-effective for targeted blood monitoring only in patients with HLA susceptibility alleles. Sensitivity analysis demonstrated that at a cost of genotype testing of up to USD700, HLA genotype-guided blood monitoring remained a cost-effective strategy compared with either current ANCM or clozapine substitution.

Low-dose computed tomography for the diagnosis of pneumonia in elderly patients: a prospective, interventional cohort study.

The diagnosis of pneumonia is challenging. Our objective was to assess whether low-dose computed tomography (LDCT) modified the probability of diagnosing pneumonia in elderly patients.We prospectively included patients aged over 65 years with a suspicion of pneumonia treated with antimicrobial therapy (AT). All patients had a chest radiograph and LDCT within 72 h of inclusion. The treating clinician assessed the probability of pneumonia before and after the LDCT scan using a Likert scale. An adjudication committee retrospectively rated the probability of pneumonia and was considered as the reference for diagnosis. The main outcome was the difference in the clinician's pneumonia probability estimates before and after LDCT and the proportion of modified diagnoses which matched the reference diagnosis (the net reclassification improvement (NRI)).A total of 200 patients with a median age of 84 years were included. After LDCT, the estimated probability of pneumonia changed in 90 patients (45%), of which 60 (30%) were downgraded and 30 (15%) were upgraded. The NRI was 8% (NRI event (-6%) + NRI non-event (14%)).LDCT modified the estimated probability of pneumonia in a substantial proportion of patients. It mostly helped to exclude a diagnosis of pneumonia and hence to reduce unnecessary AT.

[« More time for patients ¼ : a reorganization of medical wards at the University Hospitals of Geneva]. / Réorganisation interprofessionnelle du travail dans les unités de soins.

The University Hospitals of Geneva initiated their latest strategic plan by consulting widely with employees and patients. Nine main avenues were defined as priority projects for the institution. The project « More time for patients ¼ aims at simplifying clinical and administrative processes using tools from Lean management and Design Thinking. Its objectives are to redefine the organization of the healthcare-related tasks in order to optimize the time spent with patients and relatives, increase patients' involvement and shared decision making, and improve both the communication with patients, as well as the interdisciplinary collaboration, with patients always at the heart of care.

Les HUG ont initié leur dernier plan stratégique en consultant largement les collaborateurs et les patients. Neuf axes principaux ont été alors définis comme prioritaires pour l'avenir de l'institution, constituant les projets Vision 20/20. Le projet intitulé « Plus de temps pour les patients ¼ vise à optimiser le temps de présence avec les patients et les proches, à augmenter l'implication du patient dans sa prise en charge et à améliorer la communication entre les soignants et les patients, ainsi que la collaboration interdisciplinaire en gardant le patient au cœur de la démarche. Ces objectifs nécessitent la redéfinition de l'organisation des tâches médico-soignantes avec une forte implication des acteurs de terrain, et la simplification des processus cliniques et administratifs.

[Precision medicine : a required approach for the general internist]. / Médecine de précision : un rendez-vous à ne pas manquer pour l'interniste généraliste.

The general internist cannot be a passive bystander of the anticipated medical revolution induced by precision medicine. This latter aims to improve the predictive and/or clinical course of an individual by integrating all biological, genetic, environmental, phenotypic and psychosocial knowledge of a person. In this article, national and international initiatives in the field of precision medicine are discussed as well as the potential financial, ethical and limitations of personalized medicine. The question is not to know if precision medicine will be part of everyday life but rather to integrate early the general internist in multidisciplinary teams to ensure optimal information and shared-decision process with patients and individuals.

L'interniste généraliste ne peut pas être un spectateur passif du bouleversement induit par la médecine de précision. Cette dernière vise à améliorer les aspects prédictifs ou l'évolution clinique d'une personne en intégrant toutes les connaissances biologiques et génétiques, environnementales, phénotypiques et psychosociales qui lui sont propres. Dans cet article, les initiatives nationales et internationales dans ce domaine sont abordées, ainsi que les potentiels enjeux financiers, éthiques et d'équité sociale. Cette médecine de précision fera partie de notre quotidien et il s'agit d'intégrer très tôt l'interniste généraliste dans des plateformes multidisciplinaires pour assurer les restitutions d'informations, les partages de décision, les incertitudes et ultimement contribuer au maintien de la santé de la population et améliorer la qualité des soins pour nos patients.

Systemic thrombolytic therapy for acute pulmonary embolism: a systematic review and meta-analysis.

AIM: Thrombolytic therapy induces faster clot dissolution than anticoagulation in patients with acute pulmonary embolism (PE) but is associated with an increased risk of haemorrhage. We reviewed the risks and benefits of thrombolytic therapy in the management of patients with acute PE. METHODS AND RESULTS: We systematically reviewed randomized controlled studies comparing systemic thrombolytic therapy plus anticoagulation with anticoagulation alone in patients with acute PE. Fifteen trials involving 2057 patients were included in our meta-analysis. Compared with heparin, thrombolytic therapy was associated with a significant reduction of overall mortality (OR; 0.59, 95% CI: 0.36-0.96). This reduction was not statistically significant after exclusion of studies including high-risk PE (OR; 0.64, 95% CI: 0.35-1.17). Thrombolytic therapy was associated with a significant reduction in the combined endpoint of death or treatment escalation (OR: 0.34, 95% CI: 0.22-0.53), PE-related mortality (OR: 0.29; 95% CI: 0.14-0.60) and PE recurrence (OR: 0.50; 95% CI: 0.27-0.94). Major haemorrhage (OR; 2.91, 95% CI: 1.95-4.36) and fatal or intracranial bleeding (OR: 3.18, 95% CI: 1.25-8.11) were significantly more frequent among patients receiving thrombolysis. CONCLUSIONS: Thrombolytic therapy reduces total mortality, PE recurrence, and PE-related mortality in patients with acute PE. The decrease in overall mortality is, however, not significant in haemodynamically stable patients with acute PE. Thrombolytic therapy is associated with an increase of major and fatal or intracranial haemorrhage.

[Iron deficiency : a new target in treating chronic heart failure ?] / Carence en fer : une nouvelle cible thérapeutique dans l'insuffisance cardiaque ?

Iron deficiency is now recognized as an independent predictor of poor outcome in patients with chronic heart failure and reduced left ventricular ejection fraction. In randomized controlled trials, treatment with ferric carboxymaltose results in improvement in functional capacity, symptoms and quality of life, and might reduce hospitalizations. Thus, the recent European Society of Cardiology guidelines on heart failure recommend treating these patients with intravenous ferric carboxymaltose, whether or not anemic.

Récemment, la carence martiale a été reconnue comme un marqueur indépendant de mauvais pronostic dans l'insuffisance cardiaque à fraction d'éjection du ventricule gauche (FEVG) diminuée. Des études randomisées contrôlées ont démontré que l'administration de fer intraveineux améliore la capacité fonctionnelle, les symptômes et la qualité de vie de ces patients, et pourrait diminuer la fréquence des hospitalisations. Ainsi, les nouvelles recommandations de la Société européenne de cardiologie de 2016 mentionnent de traiter la carence martiale chez ces patients par l'administration intraveineuse de fer, qu'ils soient anémiques ou non.

[Faecal calprotectin : a useful tool for the primary care physician ?] / Calprotectine fécale : une utilité pour le généraliste ?

Faecal calprotectin (FC) is a marker of intestinal inflammation. FC dosing has a sensitivity between 80­100% for differentiating functional and organic intestinal disease. It is therefore a very useful diagnostic tool in general practice, where the prevalence of functional disease is particularly high. Nevertheless, FC is not specific for inflammatory bowel diseases and cannot distinguish between various inflammatory conditions. FC cut-off values are not clearly defined. Nevertheless, levels < 150 µg/g are considered ruling out organic disease and levels > 150 µg/g warrant an endoscopy. In the intermediate range 50­150 µg/g, the result is indeterminate and the decision to perform further tests should be made on an individual basis.

La calprotectine fécale (CF) est un marqueur d'inflammation intestinale dosé dans les selles. Elle a démontré une sensibilité entre 80­100 % dans la distinction entre atteintes digestives organiques et non organiques, ce qui en fait un outil diagnostique très intéressant en médecine de premier recours où la prévalence des atteintes digestives fonctionnelles est élevée. Toutefois, le dosage de la CF n'est pas spécifique pour les maladies inflammatoires de l'intestin et ne permet pas de différencier entre les différents types d'atteinte inflammatoire, et les valeurs seuils ne sont pas bien définies. En principe, une valeur < 150 µg / g exclut une pathologie organique, et une valeur > 150 µg/g est considérée comme posant l'indication à une endoscopie. Entre 50­150 µg/g, la décision de poursuivre les investigations est prise de cas en cas.

[Internal medicine in the hospital setting]. / Médecine interne hospitalière.

Progress in medical practice is often the result of a redefinition of pathologies and therapeutic targets. This is a natural translation of advances made in the pathophysiologic understanding of disease and clinical entities. In this manner, the use of biological agents is entering the field of cardiovascular medicine. This selective review of the literature summarizes certain studies published this year in the areas of internal, cardiovascular, pulmonary and thrombotic medicine.

Outcome in acute heart failure: prognostic value of acute kidney injury and worsening renal function.

BACKGROUND: The prognostic value of worsening renal function (WRF) in acute heart failure is debated. Moreover, it is not clear if the use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in this context is detrimental. METHOD AND RESULTS: In a retrospective cohort study of 646 patients hospitalized for acute heart failure, the risk of death or readmission associated with acute kidney injury (AKI) present at admission, WRF during the 1st 7 days, and up-titration of ACEI/ARB were analyzed in a Cox proportional hazards model. AKI, WRF, hemoglobin concentration, ACEI/ARB up-titration, and use of loop diuretics before admission were significantly associated with the primary outcome in univariate analysis. In a multivariate model, the association remained significant for AKI (hazard ratio [HR] 1.29, 95% confidence interval [CI] 1.13-1.47; P = .0002), WRF (HR 1.24, 95% CI 1.06-1.45; P = .0059), and ACEI/ARB up-titration (HR 0.79, 95% CI 0.64-0.97; P = .026). There was no excess mortality in patients with ACEI/ARB up-titration despite WRF. CONCLUSIONS: Both AKI and WRF are strongly associated with poor outcome in patients hospitalized for acute heart failure. ACEI/ARB up-titration seems to be protective.

Suspicion of heparin-induced thrombocytopenia in internal medicine: How appropriate is the ordering of anti-PF4/heparin antibody testing?

Thrombocytopenia is frequent in hospitalized patients, and heparin-induced thrombocytopenia (HIT) is often suspected when a decrease in platelet count is concomitant with heparin treatment. ELISA tests used for anti-PF4/heparin antibodies detection usually have high sensitivity but only fair specificity for HIT. Pre-test probability scores (such as 4 Ts or HEP scores) have been validated and a low probability score rules out HIT without anti-PF4/heparin testing. The aims of this study are to evaluate the appropriateness of anti-PF4/heparin testing according to pre-test probabilities of HIT and to compare the abilities of the 4 Ts and HEP scores to avoid inappropriate anti-PF4/heparin testing. This retrospective observational study included 74 consecutive patients hospitalized in a general internal medicine division who had anti-PF4/heparin testing for suspicion of HIT. 4 Ts and HEP scores were computed retrospectively. About 73% of patients who had ordering of an anti-PF4/heparin were at low risk according to the 4 Ts score, and 46% according to the HEP score. Heparin was discontinued in 61% and 62% of low-risk patients according to 4 Ts and HEP scores and switched to alternative anticoagulant in 31% and 32% of them, respectively. No case of HIT was diagnosed in patients with a low-risk score. One major bleeding and no thrombosis were observed. For the 4 Ts score, the sensitivity was 100%, the negative predictive value (NPV) was 100%, the specificity was 77%, and the positive predictive value (PPV) was 20% (95% CI: 7-44). For the HEP score, the sensitivity was 100%, the NPV was 100%, the specificity was 49%, and the PPV was 10%. In conclusion, pre-test probability scores were vastly underused in this internal medicine population despite their ability to rule out HIT without laboratory testing in a large proportion of patients. Appropriate use of those instruments should be actively promoted.

[Challenges and opportunities related to the creation of a unique society of specialists in general internal medicine in 2015]. / Défis et opportunités liés a la création d'une société unique de spécialistes en médecine interne générale en 2015.

A common training plan in general internal medicine was a brave enterprise started in 2011 in accordance with the common objectives of the Swiss Society of General Medicine and the Swiss Society of Internal Medicine. The next challenge will be the dissolution of the two Societies and therefore the creation of an unique new association in 2015. This is an extraordinary opportunity to bring together the specific qualities of each association and to create a new society. Issues, objectives and secondary benefits expected from the creation of the largest national society of a medical discipline are explored as a joint discussion in this article.

[A review of hospital based internal medicine in 2013]. / Médecine interne hospitalière: l'année 2013 en revue.

The last few years have seen many studies, pharmacological molecules, and procedures addressing frequent clinical presentations and scenarios. The multiplicity of therapeutic options for, as examples, anticoagulation, the treatment of anaemia, glycemic control, closure of cardiac defects, nevertheless require validation so that medical practice can be based on clear therapeutic objectives, evidence of its effectiveness, and a certain economic viability. This selective review of the literature summarizes certain studies published this year.

Pulmonary embolism risk stratification: external validation of the 4-level Clinical Pretest Probability Score (4PEPS).

Background: The 4-level clinical pretest probability score (4PEPS) was recently introduced as a clinical decision rule for the diagnosis of pulmonary embolism (PE). Based on the score, patients are classified into clinical pretest probability categories (c-PTP). The "very low" category aims at excluding PE without further testing; "low" and "moderate" categories require D-dimer testing with specific thresholds, while patients with a "high" pretest directly proceed to imaging. Objectives: To provide further external validation of the 4PEPS model. Methods: The 4PEPS was applied to a previously collected prospective database of 756 patients with clinically suspected PE enrolled from European emergency departments in 2002 to 2003. The safety threshold for the failure rate in our study was calculated at 1.95% based on a 26% prevalence of PE in our study, as per the International Society on Thrombosis and Haemostasis Scientific and Standardization Committee guidance. Results: Patients were classified as follows: 90 (12%) in the very low c-PTP group, of whom 5 (5.6%; 95% CI, 2.4%-12.4%) had PE; 363 (49%) in the low c-PTP group, of whom 34 had PE (9.4%); 246 (34%) in the moderate c-PTP group, of whom 124 (50%) had PE; and 35 (5%) in the high c-PTP group of whom 30 (86%) had PE. Overall, the failure rate of the 4PEPS was 9/734 (1.2%; 95% CI, 0.59%-2.23%) Overall, 9 out of 734 patients (1.2%; 95% CI, 0.59%-2.23%) were diagnosed with PE despite a negative 4PEPS rule; 5 (5.6%) from the very low c-PTP group, 3 (1.4%) in the low c-PTP group, and 1 (3.2%) in the moderate c-PTP group. Conclusion: We provide external validation data of the 4PEPS. In this high-prevalence cohort (26% prevalence), PE prevalence in the very low-risk group was higher than expected. A prospective validation study is needed before implementing the 4PEPS model in routine clinical practice.

Echocardiography and pulmonary embolism severity index have independent prognostic roles in pulmonary embolism.

We analysed a cohort of patients with normotensive pulmonary embolism (PE) in order to assess whether combining echocardiography and biomarkers with the pulmonary embolism severity index (PESI) improves the risk stratification in comparison to the PESI alone. The PESI was calculated in normotensive patients with PE who also underwent echocardiography and assays of cardiac troponin I and brain natriuretic peptide. 30-day adverse outcome was defined as death, recurrent PE or shock. 529 patients were included, 25 (4.7%, 95% CI 3.2-6.9%) had at least one outcome event. The proportion of patients with adverse events increased from 2.1% in PESI class I-II to 8.4% in PESI class III-IV, and to 14.3% in PESI class V (p<0.001). In PESI class I-II, the rate of outcome events was significantly higher in patients with abnormal values of biomarkers or right ventricular dilatation. In multivariate analysis, the PESI (class III-IV versus I-II, OR 3.1, 95% CI 1.2-8.3; class V versus I-II, OR 5.5, 95% CI 1.5-25.5 and echocardiography (right ventricular/left ventricular ratio, OR (for an increase of 0.1) 1.3, 95% CI 1.1-1.5) were independent predictors of an adverse outcome. In patients with normotensive PE, biomarkers and echocardiography provided additional prognostic information to the PESI.

Including patients in resuscitation decisions in Switzerland: from doing more to doing better.

BACKGROUND: Decisions regarding Cardio-Pulmonary Resuscitation (CPR) and Do Not Attempt Resuscitation (DNAR) orders remain demanding, as does including patients in the process. OBJECTIVES: To explore physicians' justification for CPR/DNAR orders and decisions regarding patient inclusion, as well as their reports of how they initiated discussions with patients. METHODS: We administered a face-to-face survey to residents in charge of 206 patients including DNAR and CPR orders, with or without patient inclusion. RESULTS: Justifications were provided for 59% of DNAR orders and included severe comorbidity, patients and families' resuscitation preferences, patients' age, or poor prognosis or quality of life. Reasons to include patients in CPR/DNAR decisions were provided in 96% and 84% of cases, and were based on respect for autonomy, clinical assessment of the situation as not too severe, and the view that such inclusion was required. Reasons for not including patients were offered in 84% of cases for CPR and in 70% for DNAR. They included absent decision-making capacity, a clinical situation viewed as good (CPR) or offering little hope of recovery (DNAR), barriers to communication, or concern that discussions could be emotionally difficult or superfluous. Decisions made earlier in the patient's management were infrequently viewed as requiring revision. Residents reported a variety of introductions to discussions with patients. CONCLUSIONS: These results provide better understanding of reasons for CPR/DNAR decisions, reasons for patient inclusion or lack thereof, and ways in which such inclusion is initiated. They also point to potential side-effects of implementing CPR/DNAR recommendations without in-depth and practical training. This should be part of a regular audit and follow-up process for such recommendations.