Impediments to writing do-not-resuscitate orders.

BACKGROUND: Physicians are frequently unaware of their patients' desires regarding end-of-life care. Consequently, opportunities to implement do-not-resuscitate (DNR) orders are often missed. OBJECTIVE: To determine the reasons attending physicians do not write DNR orders when patients face increased mortality. METHODS: Over 4 months, the medical records of all inpatients on the General Medicine Service were reviewed at the time of discharge to identify patients with conditions predicting increased mortality. These cases were presented to a 5-member panel who decided if a DNR order was indicated. Reasons for missing DNR orders were discussed with the attending physicians. RESULTS: Of 613 consecutive admissions, the panel identified 149 patients (24%) for whom DNR orders were indicated. In 88 (59%) of these, DNR orders were absent. The lack of a DNR order did not correlate with age (P = .95), sex (P = .61), or race (P = .80). The attending physicians' explanations for not writing DNR orders in these 88 cases included the belief that the patient was not in imminent danger of death (n = 49 [56%]), the belief that the primary physician should discuss DNR issues (n = 43 [49%]), and the lack of an appropriate opportunity to discuss end-of-life issues (n = 38 [43%]). In 11 (12%) of the 88 cases, patients or their families did not accept the recommendation for a DNR order. No physicians expressed concerns regarding the morality of DNR orders, discomfort discussing end-of-life issues, or the threat of litigation as reasons for not writing a DNR order. CONCLUSIONS: Limitations in the extent and depth of the physician-patient relationship appear to be the most frequent impediments to writing DNR orders in our institution.

Circulating D dimer in patients with sarcoidosis.

STUDY OBJECTIVES: To determine the relationship between D dimer (DD) status and markers of disease activity in patients with sarcoidosis. DESIGN: Prospective, observational analysis. SETTING: Pulmonary clinic of a tertiary care, university-affiliated hospital. PATIENTS: Consecutive individuals with newly diagnosed sarcoidosis. INTERVENTION: Determination of serum DD. MEASUREMENTS AND RESULTS: The study cohort included 28 subjects, and DD was present in 39.3%. DD status correlated with the radiographic stage of disease (p = 0. 035), diffusing capacity of the lung for carbon monoxide (p = 0.026), serum angiotensin-converting enzyme level (p = 0.006), and the presence of dyspnea (p = 0.034). Patients with circulating DD were 3. 8 times more likely to have radiographic evidence of interstitial involvement. DD was not associated with either FVC or the FEV(1). CONCLUSIONS: DD is frequently positive in patients with sarcoidosis. DD is associated with disease activity as measured by radiograph, pulmonary function tests, and serum markers of inflammation.

Continuous subglottic suctioning for the prevention of ventilator-associated pneumonia : potential economic implications.

STUDY OBJECTIVE: To determine the cost-effectiveness of continuous subglottic suctioning (CSS) as a strategy to decrease the incidence of ventilator-associated pneumonia (VAP). DESIGN: Decision-model analysis of the cost and efficacy of endotracheal tubes that allow CSS at preventing VAP. The primary outcome was cases of VAP averted. Model estimates were based on data from published prospective trials of CSS and other prospective studies of the incidence of VAP. SETTING AND PATIENTS: Hypothetical cohort of 100 patients requiring nonelective endotracheal intubation and management in an ICU. INTERVENTIONS: In the model, patients were managed with either traditional endotracheal tubes (ETs) or ETs capable of CSS. MEASUREMENTS AND MAIN RESULTS: The marginal cost-effectiveness of CSS was calculated as the savings resulting from cases of VAP averted minus the additional costs of CSS-ETs, and expressed as cost (or savings) per episode of VAP prevented. Sensitivity analysis of the impact of the major clinical inputs on the cost-effectiveness was performed. The base case assumed that the incidence of VAP in patients requiring > 72 h of mechanical ventilation (MV) was 25%, that CSS-ETs had no impact on patients requiring MV for < 72 h, and that CSS-ETs resulted in a relative risk reduction of VAP of 30%. Despite the higher costs of ETs capable of CSS, this tactic yielded a net savings of $4,992 per case of VAP prevented. For sensitivity analysis, model inputs were adjusted by 50% individually and then simultaneously. This demonstrated the model to be only moderately sensitive to the calculated cost of VAP. With the relative risk reduction at 50% of the base-case estimate, CSS resulted in $1,924 saved per case of VAP prevented. When all variables were skewed against CSS, total outlays were trivial (approximately $14 per patient in the cohort). CONCLUSIONS: CSS represents a strategy for the prevention of VAP that may result in savings. Further studies are warranted to confirm the efficacy of CSS.

Endobronchial involvement and airway hyperreactivity in patients with sarcoidosis.

STUDY OBJECTIVE: To determine the relationship between airway hyperreactivity (AHR) and endobronchial involvement in patients with sarcoidosis. DESIGN: Prospective series of consecutive patients. SETTING: Pulmonary clinic of a military, tertiary-care teaching hospital. PATIENTS: Patients with newly diagnosed sarcoidosis. INTERVENTIONS: All patients undergoing bronchoscopy for the diagnosis of sarcoidosis underwent an evaluation that included history, physical examination, chest radiography, and spirometry. Bronchoprovocation testing was done using methacholine. During bronchoscopy, six endobronchial biopsy (EBB) specimens were obtained. In patients with abnormal-appearing airways, four specimens were obtained from abnormal areas and two specimens were obtained from the main carina. In patients with normal-appearing airways, four specimens were obtained from a secondary carina and two specimens were obtained from the main carina. A biopsy specimen was considered positive if it demonstrated nonnecrotizing granulomas with special stains that were negative for fungal and mycobacterial organisms. Only patients with histologic confirmation of sarcoidosis were included in the data analysis. MEASUREMENTS AND RESULTS: The study cohort included 42 patients (57.1% were men, 61.9% were African American, and mean age [+/- SD] was 37.3 +/- 6.6 years). AHR was present in nine patients (21.4%), while EBB revealed nonnecrotizing granulomas in 57.1% of patients. All patients with AHR had positive EBB findings compared to 45.5% of individuals without AHR (p = 0.005). There was a trend toward lower lung volumes and flow rates in patients with AHR, but this did not reach statistical significance. The mean serum angiotensin-converting enzyme level was higher in patients with AHR (79.3 +/- 53.9 IU/L vs 37.5 +/- 26.7 IU/L, p = 0.05). No other clinical variable correlated with the presence of AHR. CONCLUSIONS: AHR may be seen in patients with sarcoidosis. Endobronchial involvement significantly increases the risk for AHR and may play a role in the development of AHR in patients with sarcoidosis. Other clinical factors are not clearly associated with AHR in patients with sarcoidosis.

Endobronchial biopsy for sarcoidosis: a prospective study.

STUDY OBJECTIVES: To determine the yield of endobronchial biopsy (EBB) for suspected sarcoidosis, and to evaluate if EBB increases the diagnostic value of fiberoptic bronchoscopy (FOB) when added to transbronchial biopsy (TBB). DESIGN: Prospective study of consecutive patients. SETTING: Pulmonary clinic of a tertiary-care, academic medical center. PATIENTS: Patients consecutively referred for suspected pulmonary sarcoidosis. INTERVENTIONS: All patients having FOB performed underwent an evaluation that included history, physical examination, a chest radiograph, and spirometry. During FOB, airway appearance was recorded and both TBB and EBB were performed in a standardized fashion. Six TBB specimens were obtained, as were six EBB samples. For patients with abnormal-appearing airways, four specimens were obtained from the abnormal-appearing airways and two specimens were obtained from the main carina. In patients with normal-appearing airways, four specimens were obtained from a secondary carina and two specimens were obtained from the main carina. A biopsy finding was considered positive if it demonstrated nonnecrotizing granulomas with special stains that were negative for fungal and mycobacterial organisms. MEASUREMENTS AND RESULTS: The study cohort included 34 subjects (mean +/- SD age, 37.9 +/- 6.8 years; 58.8% were male; 64.7% were African American). EBB findings were positive in 61.8% of patients, while TBB showed nonnecrotizing granulomas in 58.8% of subjects. The addition of EBB increased the yield of FOB by 20.6%. Although EBB findings were more frequently positive in abnormal-appearing airways (p = 0.014), EBB provided diagnostic tissue in 30.0% of patients with normal-appearing endobronchial mucosa. There were no complications resulting from the addition of EBB to TBB. CONCLUSIONS: Endobronchial involvement is common in sarcoidosis. EBB has a yield comparable to TBB and can safely increase the diagnostic value of FOB. Pulmonologists should consider routinely performing EBB in cases of suspected sarcoidosis.

Endobronchial disease and racial differences in pulmonary sarcoidosis.

In a retrospective review of 7 years of Walter Reed Army Medical Center fiberoptic bronchoscopy records, 154 patients with biopsy specimen proved (122) and clinically diagnosed (32) sarcoidosis were identified. Endobronchial mucosal appearance was normal in only 70 (45%). Abnormal mucosal findings included erythema (29 patients), nodules (13), plaques (13), and cobblestoning (29). Fifty-nine patients were evaluated with endobronchial biopsies (EBBX), and non-necrotizing granulomata diagnostic of sarcoidosis were found in 42 (71%). The diagnostic yield from endobronchial biopsies was similar regardless of the type of mucosal abnormality. EBBX specimens were diagnostic in 85% of black patients and 38% of white patients (p = 0.00081), but diagnostic yield did not correlate with patient's sex, symptoms, radiographic stage of disease, or extent of physiologic abnormalities. Four patients with normal-appearing bronchial mucosa underwent EBBX, and sarcoidosis was diagnosed in two. Transbronchial lung biopsy (TBBX) specimens were diagnostic of sarcoidosis in 61 of 82 (74%) black and 28 of 56 (50%) white patients (p = 0.0038). We conclude that the bronchial mucosa appears abnormal in the majority (55%) of patients with sarcoidosis. EBBX specimens will diagnose sarcoidosis in a high percentage of such patients and should be performed routinely. EBBX may be preferable to TBBX because of its greater safety profile. In our patients, the yield of both EBBX and TBBX was significantly greater in African-Americans than white Americans.

Mechanical ventilation in hematopoietic stem cell transplantation: can We effectively predict outcomes?

BACKGROUND: Survival rates from mechanical ventilation (MV) in allogeneic bone marrow transplantation are poor, but little is known about the need for and outcomes from MV in patients who undergo autologous hematopoietic stem cell transplantation (AHSCT). STUDY OBJECTIVE: To determine the frequency of and risk factors for the use of MV in recipients of AHSCT and to identify predictors of survival in mechanically ventilated AHSCT patients. DESIGN: Retrospective, cohort analysis SETTING: Tertiary-care, university-affiliated medical center. PATIENTS: One hundred fifty-nine consecutive patients who underwent AHSCT. INTERVENTIONS: Patient surveillance and data collection. MEASUREMENTS AND RESULTS: The primary outcome measure was the need for MV, and the secondary end point was survival after MV. Of 159 patients, 17 required MV (10. 7%). Three variables were associated with the need for MV: increasing age, use of total body irradiation in the conditioning regimen, and treatment with amphotericin B. As a screening test to predict the need for MV, no risk factor had a sensitivity or specificity > 82%. Three of the 17 mechanically ventilated patients (17.6%) survived to discharge. Only the mean APACHE (acute physiology and chronic health evaluation) II score separated survivors from nonsurvivors (21.7 vs 31.4; p = 0.029). Both the duration of MV and the length of stay in the ICU were similar in survivors and nonsurvivors. CONCLUSIONS: We conclude that MV is infrequently needed following AHSCT. Although survival after MV in these patients is limited, clinical variables do not reliably allow clinicians to prospectively identify patients destined to die.

Aspergillus and endobronchial abnormalities in lung transplant recipients.

STUDY OBJECTIVE: To determine the relationship between aspergillus recovery from the airways of lung transplant recipients and the development of endobronchial abnormalities. DESIGN: Retrospective case series. SETTING: Tertiary-care hospital. PATIENTS: All patients who underwent lung transplantation between December 1991 and June 1999. MEASUREMENTS AND RESULTS: The study cohort included 38 patients. The primary end point was the bronchoscopic identification of an endobronchial abnormality. Aspergillus was isolated from the lungs of nine patients (23.7%). Most of these isolates occurred early after transplantation (mean, 8 weeks). Endobronchial abnormalities arose in seven of the patients (18.4%) and manifested as either exuberant granulation tissue or stricture formation. Six of the 9 (66.6%) patients with aspergillus developed airway lesions, compared to 1 of the 29 patients (3.4%) without aspergillus (p = 0.0002). Endobronchial abnormalities were 19.3 times more likely to occur in patients in whom aspergillus had previously been isolated. As a screening test for the subsequent diagnosis of an airway complication, the recovery of aspergillus had a sensitivity and specificity of 85.7% and 90.3%, respectively. These aspergillus-related endobronchial abnormalities were clinically relevant as evidenced by a mean increase of 25.9% in the FEV(1) after bronchoscopic intervention. CONCLUSION: The early isolation of aspergillus from the airways of lung transplant recipients identifies patients at increased risk for the development of clinically significant endobronchial abnormalities.

D-dimer assay predicts mortality in critically ill patients without disseminated intravascular coagulation or venous thromboembolic disease.

OBJECTIVE: To determine if D-dimer predicts outcomes in critically ill patients. DESIGN: Observational, cohort study. SETTING: Medical intensive care unit (MICU) of a tertiary care hospital. PATIENTS AND PARTICIPANTS: Seventy-four patients consecutively admitted to the MICU. INTERVENTIONS: D-dimer was measured by latex agglutination within 12 h of admission to the MICU. MEASUREMENTS AND RESULTS: Of the study population, 43.2% had positive D-dimers. The in-hospital mortality rate in D-dimer positive patients was 28.1% as compared to 7.1% in D-dimer negative subjects (p = 0.024). D-dimer positive patients had significantly greater frequencies of venous thromboses (21.9% vs 4.8%, p = 0.035). CONCLUSIONS: The D-dimer assay identifies patients at increased risk for mortality and may be a more sensitive test to determine the presence of underlying microvascular pathology in critically ill patients. A positive D-dimer at admission to the MICU is associated with an increased risk for the later development of a venous thromboembolic event (VTE).

Regulatory and educational initiatives fail to promote discussions regarding end-of-life care.

We conducted an observational cohort study to determine if hospital-based, reinforcing regulatory and educational interventions could encourage physicians to discuss end-of-life (EOL) care with their patients. Specifically, we measured the effect of (1) administrative prompts to encourage discussions about EOL care and (2) a mandatory educational seminar focusing on EOL issues. Study subjects were patients consecutively admitted to the medicine service who faced an anticipated 3-year mortality rate of at least 50%. The main study endpoint was the frequency of documented EOL discussions between physicians and patients. In the inception cohort of 184 patients, physicians discussed EOL care with 64 patients (34. 8%), and in the follow-up cohort of 121 patients, 41 individuals (33. 9%) had documented discussions regarding EOL issues (P = 0.90). Actual "Do Not Resuscitate"(DNR) orders were written for 53 patients (28.8%) in the inception cohort and for 33 persons (27.3%) in the follow-up cohort (P = 0.71). We conclude that enhanced, mutually reinforcing regulatory and educational efforts focusing on EOL care proved ineffectual at promoting either discussions about EOL issues or the use of DNR orders.

The effect of a class in medical ethics on first-year medical students.

PURPOSE: To assess the effect of a class in medical ethics on first-year medical students. METHOD: A test instrument was developed to measure the attitudes of medical students toward certain ethical questions and to assess their factual knowledge regarding particular legal and ethical issues. The instrument was administered in 1992-93 to 110 first-year students at the University of Virginia School of Medicine before and after the students took a required course in medical ethics. The instrument employed clinical vignettes as well as multiple-choice, true-false, and Likert-scale questions. Its reliability and validity were assessed. RESULTS: The required course in medical ethics had little influence on the students. There was only one significant change (p = .05) in the pattern of responses to any of the clinical vignettes. In a few of the attitude-oriented queries, there were statistically significant changes (p < .05) after the course. Although there were statistically significant changes for only four of the factual-knowledge questions, for all such questions more students identified the correct answers after the class (before the course the range of correct answers was 43% to 99% compared with 64% to 100% after the course). CONCLUSION: The class in medical ethics seemed to have little effect on the first-year students, probably because students arrive at medical school with well-established ethical perspectives.

Osseous disease in patients with pulmonary sarcoidosis and musculoskeletal symptoms.

Little is known about the clinical manifestations and correlates of osseous sarcoidosis and few data exist to guide pulmonologists in their evaluation of patients for possible osseous involvement. To determine the relationship between pulmonary and osseous sarcoidosis, and to develop an algorithm for use by pulmonologists in assessing patients with suspected osseous sarcoidosis, we conducted a retrospective, case control study of patients with pulmonary sarcoidosis and musculoskeletal complaints who were evaluated for osseous disease. All patients underwent a standard evaluation to include physical examination, chest radiograph (CXR), spirometry (PFTs), bone scintigraphy and plain radiographs of the hands and feet. Patients completed a health assessment questionnaire and serum angiotenisin converting enzyme, erythrocyte sedimentation rate, and C-reactive protein were measured. Patients eventually diagnosed with osseous sarcoidosis were compared to those lacking osseous involvement. Osseous involvement in patients with pulmonary sarcoidosis and musculoskeletal symptoms was common and seen in 38.9% of subjects. Patients with osseous sarcoidosis were more likely to concomitantly suffer from cutaneous sarcoidosis and to have elevated ACE levels and ESRs. No measure of pulmonary involvement (CXR stage, PFTs or symptoms) differentiated patients with osseous sarcoidosis from those without this condition. In cases of osseous sarcoidosis, bone scintigraphy identified a mean of four sites of osseous involvement, some of which would have been missed with the use of plain radiographs limited to the hands and feet. We conclude that in patients with pulmonary sarcoidosis who have significant musculoskeletal complaints, osseous involvement is frequent. Pulmonary features of sarcoidosis do not differ between patients with and without osseous disease. Bone scintigraphy aids in the evaluation of these patients.

Serum angiotensin converting enzyme does not correlate with radiographic stage at initial diagnosis of sarcoidosis.

Serum levels of angiotension converting enzyme (ACE) are elevated in many patients who suffer from sarcoidosis. Few studies have correlated ACE levels at diagnosis with the radiographic stage of the disease. The present authors reviewed the charts of all patients who had the diagnosis of sarcoidosis made between 1990 and 1995, and correlated ACE level at diagnosis with radiographic stage. Only patients with biopsy-proven sarcoid were included. One hundred and sixteen cases were identified, and complete data were available for 104 individuals. Serum ACE levels were increased in approximately 63.5% of the study population. The relationships between both stage and ACE level, and stage and percentage of individuals with elevated ACE levels within that stage were not statistically significant (P > 0.05). This large, retrospective study of patients with histologic evidence of sarcoidosis demonstrated no association between serum ACE level and radiographic stage.

Dermatomyositis and malignant melanoma.

Patients with dermatomyositis may face an increased risk of malignancy. Malignant melanoma has been linked to dermatomyositis. We present a case of concomitant dermatoyositis and metastatic malignant melanoma and review the English literature concerning this topic. Analysis revealed that the development of dermatomyositis in patients with malignant melanoma heralds the diagnosis of metastatic disease. These patients face dismal prognoses.

The American College of Physicians' Resident Abstract Competition: success of U.S. military trainees.

Research is a central aspect of internal medicine (IM) training, and accreditation organizations require that residency programs show that their residents participate in scholarly activity. To better understand the research productivity and the quality of research conducted by military IM trainees, we reviewed the records of the American College of Physicians' Resident Abstract Competition from 1995 to 1997. This national competition is prestigious, blindly judged, and highly selective. We found that although military residents account for less than 2% of all U.S. and Canadian IM trainees, they author more than 11% of the abstracts selected for presentation (p < 0.001). We conclude that military IM residents are disproportionately represented compared with their civilian peers in an objective, national competitive forum. This is consistent with the higher scores on in-service examinations and higher board-certification pass rates for military IM residents.

Impact of stage 3B chronic kidney disease on thrombosis and bleeding outcomes after orthopedic surgery in patients treated with desirudin or enoxaparin: insights from a randomized trial.

BACKGROUND: Venous thromboembolism (VTE) remains a significant complication of major orthopedic surgery, and chronic kidney disease (CKD) is common among elderly patients undergoing total hip replacement (THR). OBJECTIVES: The purpose of this study was to evaluate thrombosis and bleeding outcomes in patients with stage 3B CKD treated with either desirudin or enoxaparin after elective THR. PATIENTS/METHODS: This was a post hoc subgroup analysis of a randomized, multicenter, double-blind study of desirudin vs. enoxaparin in patients undergoing elective THR. RESULTS: Patients received either subcutaneous desirudin 15 mg twice daily or subcutaneous enoxaparin 40 mg once daily. Of the 2078 randomized patients who received study medication, 577 had stage 3B CKD or worse (27.8%), and the proportion of these patients who experienced a major VTE in the enoxaparin treatment group was found to be much higher than in the desirudin treatment group (11.1% vs. 3.4%, model-adjusted odds ratio 3.52, 95% confidence interval 1.48-8.40, P=0.004). There was no statistically significant difference between treatment groups in terms of rates of major bleeding, regardless of stage of renal function. CONCLUSIONS: CKD has been reported previously to increase the risk of bleeding with anticoagulants, and these findings suggest that CKD may also increase the risk of major VTE for patients treated with enoxaparin, but not for patients treated with desirudin. Clinicians should consider the impact of CKD on the risk of VTE when choosing a prophylaxis agent.

Evaluating the role for the optical density in the diagnosis of heparin-induced thrombocytopenia following cardiac surgery.

The poor accuracy of the enzyme immune assay (EIA) contributes to the diagnostic challenge of heparin-induced thrombocytopenia (HIT) following cardiac surgery. We sought to determine if adjusting the threshold optical density (OD) defining a positive EIA improves the test's accuracy in subjects with an OD>0.40. We retrospectively analysed the results from both EIA and confirmatory serotonin release assays (SRAs) in cardiac surgery patients with EIA OD of >0.4. Employing the SRA as the standard, we compared the area under the receiver-operating characteristic (AUROC) curves of various OD measurements for identifying HIT. We examined baseline clinical variables associated with a positive SRA in the setting of a positive HIT EIA (OD >0.4). We then used logistic regression to identify baseline clinical variables independently associated with a positive SRA given a positive EIA. The cohort included 99 subjects with positive EIAs and 35% had positive SRAs. An OD>0.40 had moderate utility as a screening test for a positive SRA (AUROC: 0.68; 95% CI: 0.55-0.80). Increasing the OD threshold did not improve the HIT EIA's screening utility. Clinical variables independently associated with a positive SRA if the EIA were positive included female gender, absence of diabetes, and use of cardiopulmonary bypass. A relatively modest elevation in the OD measurement, when it is already known to be greater than 0.4, does not reliably exclude the potential for a positive SRA in this setting.

Understanding cost-effectiveness.

Healthcare delivery in the USA and abroad has changed dramatically over the last several decades. Along with the growth in diagnostic and therapeutic interventions, the costs of healthcare have escalated out of proportion relative to other aspects of the economy. This growth has fostered careful scrutiny of both the effectiveness and efficiency of healthcare delivery. Because of this emphasis on the economics of healthcare, physicians require an understanding not only of the efficacy and clinical utility of their interventions, but also of the relative value in an economic sense of their efforts. In other words, physicians in the modern era must now appreciate the concept of cost-effectiveness. Cost-effectiveness and cost-utility analyses are critical evaluative tools. Explicit data on comparative cost-effectiveness are useful for allocating the increasingly stretched healthcare resources. This article provides a primer for understanding the methods and applications of cost-effectiveness and cost-utility analyses.

The validation and reproducibility of the pulmonary embolism severity index.

SUMMARY BACKGROUND: Rapid, accurate risk stratification is paramount in managing patients with acute pulmonary embolism (PE). The PE Severity Index (PESI) is a simple tool that risk stratifies patients with acute PE. OBJECTIVES: We sought to validate the PESI as a predictor of short- and intermediate-term mortality and to determine the inter-rater variability. PATIENTS/METHODS: We retrospectively identified all patients with acute PE between October 2007 and February 2009. Two clinicians reviewed charts and independently scored PESI blinded to each other and to patient outcomes. Thirty- and 90-day mortality served as study endpoints and vital status was assessed via the Social Security Death Index. To facilitate analyses, raw PESI score was converted into risk class groups (I-V) and further dichotomized into low risk (I-II) vs. high risk (III-V) groups. Intraclass correlation and the kappa statistic were used to determine inter-rater variability. RESULTS: The cohort included 302 subjects (mean age, 59.7 +/- 17.2 years; 44% male). All-cause 30- and 90-day mortalities were 3.0% and 4.0%, respectively. The mortality rate increased as raw PESI score increased. Risk of death correlated with risk class (P < 0.001). There were no deaths in risk classes I-III, but 30- and 90-day mortality for class V were 9.2% and 10.5%, respectively. Overall, mean PESI scores were similar between observers: 103.3 +/- 39.3 and 96.5 +/- 37.6 (P = NS). The inter-rater variability was good (kappa = 0.69; P < 0.0001). CONCLUSIONS: The PESI correlates with 30- and 90-day mortality. It represents a reproducible scoring tool to risk stratify patients with acute PE.