Evaluation of the pulmonary embolism rule-out criteria in a retrospective cohort at an urban academic hospital.

BACKGROUND: The pulmonary embolism rule-out criteria (PERC) is an 8-variable clinical decision rule that identifies patients at low risk for pulmonary embolism (PE) to prevent unnecessary diagnostic testing in the evaluation of suspected PE in the emergency department (ED). The objective of this study was to determine PERC's safety and diagnostic use in our institution's ED population. METHODS: We performed a retrospective analysis on consecutive adult patients evaluated with computed tomographic angiography (CTA) for suspicion of PE at our ED during the dates January 1, 2011, to December 31, 2011. Patients negative for all 8 PERC criteria (ie, "PERC [-]") were considered to be at low risk for PE. All data were analyzed using SPSS-20 (SPSS Inc, Chicago, IL) to calculate the variables of interest and their respective 95% confidence intervals (95% CIs). RESULTS: During the 12-month study period, 729 subjects were evaluated with CTA for suspicion of PE. Ten subjects were excluded because of nondiagnostic imaging studies. After exclusion, 719 subjects were available for analysis. Prevalence of PE was 4.5%. PERC (-) had a sensitivity of 96.9% (95% CI, 84.3%-99.4%), a negative predictive value of 98.8% (95% CI, 93.5%-99.8%), and a negative likelihood ratio of 0.26 (95% CI, 0.04-1.82) when used as an independent diagnostic test to exclude PE. CONCLUSIONS: Use of PERC could have safely avoided 11.5% of CTAs, reducing potential patient harm, health care costs, and unnecessary diagnostic testing. Consistent with prior studies, PERC can be safely used to identify low-risk patients for whom further testing can be deferred.

Clinical features in patients with pulmonary embolism at a community hospital: analysis of 4 years of data.

The aim of this study is to assess the various clinical features, risk factors, and electrocardiographic (EKG) findings associated with acute pulmonary embolism (PE). Knowledge gained from the study may enable health care providers in diagnosis of PE, thus allowing them to carry out appropriate diagnostic testing and treatment after recognition of this potentially lethal disease. PE is common but frequently under-diagnosed clinical problem, associated with potentially fatal outcomes. Clinical presentation is highly variable, non-specific and most patients have an underlying identifiable risk factor. The presentation of PE can easily be confused with other cardio-pulmonary or systemic disorders. Prompt diagnosis of this potentially deadly disease is of utmost importance. Knowledge of salient features associated with PE may enable health care providers in diagnosis of PE, thus allowing them to carry out appropriate diagnostic testing and treatment after its recognition. We performed a single-center, cross-sectional descriptive study including all inpatient and emergency department encounters ≥18 years of age diagnosed with PE at our institution, a 300-bed inner city community hospital, during the dates January 2007 to December 2010. All patients were diagnosed with multi-detector 64-slice spiral computed tomography angiography. Using a standardized form, we performed simultaneous retrospective chart review to collect the necessary data required for the study. PE was confirmed in 334 patients during the 4 years study period. Mean age of subjects was 65.8 years (±16.4, range 22-98). Females represented 54 % of study subjects. Dyspnea, chest pain, and cough were present in 72, 38, and 19 % of the patients, respectively. Dyspnea was the only presenting symptom in 29 %. Tachypnea, hypoxia, tachycardia, and signs of DVT were present in 39, 35, 33, and 29 %, respectively. Cancer was most common risk factor present in 27 %, followed by prior history of venous thromboembolism (DVT or PE), immobilization, and surgery in 19, 15, and 15, respectively. EKG interpretation revealed normal sinus rhythm in 53 %, sinus tachycardia in 31 %, S1Q3T3 pattern in 6 %, and atrial fibrillation (AF) in 6 %.We also noted that 8 % of elderly patients had new onset AF at the time of diagnosis of PE. Diagnosis of PE remains a challenging task due to its variable presentation. Many of the classical features associated with this potentially fatal disease are often missing. This data re-emphasizes a wide spectrum of clinical presentation and non-specificity of symptoms of PE. Clinical suspicion of PE is a critical step and of paramount importance for further objective investigations, which would assist in the diagnosis and appropriate timely management of PE.

A review of venous thromboembolism prophylaxis for hospitalized medical patients.

In the last decade, greater focus has been directed toward venous thromboembolism (VTE) prophylaxis in hospitalized, non-surgical patients. Both deep venous thrombosis and pulmonary embolism are potentially preventable causes of patient morbidity and mortality related to hospitalization. Despite the availability of high-quality, evidence-based guidelines for VTE prevention, there is compelling evidence that many hospitalized patients do not receive appropriate VTE prevention measures. Hospitalists play an important role in the implementation of appropriate VTE prophylaxis measures for this patient population; thus, knowledge of updated recommendations is vital to their practice, as well as patient safety. We provide a comprehensive evidence-based clinical review of VTE prophylaxis for nonsurgical hospitalized patients, including risk factors and risk assessment, indications for prophylaxis, recommended therapeutic options, and updates from recently released practice guidelines by the American College of Physicians and the American College of Chest Physicians, published in 2011 and 2012, respectively.

A longitudinal study of sociodemographic predictors of hemoglobin A1c.

This research examined sociodemographic predictors of hemoglobin A1c (HbA1c) among diabetic patients in an outpatient urban medical center. All patients with diabetes during a 7.5-year period were selected. Regression analyses determined the association of the last HbA1c level with insurance, ethnicity, age, gender, marital status, employment, socialsecuritynumber (present/absent), and number of clinic visits. Patients (N=748) were followed an average of 3.2 years. After multivariate adjustment, the following variables predicted a higher value for the last HbAlc (P < 0.05): Absence of insurance, African American ethnicity, Hispanic ethnicity, younger age, and fewer clinic visits per year. These relationships to HbA1c persisted after adjustment for follow-up duration and after limiting the analysis to patients with type 2 diabetes only (N=662). In conclusion, absence ofhealthinsurance, ethnicity, young age, and fewer clinic visits are independent predictors of HbAlc and should be given consideration in diabetes research and glycemic control.