Subsegmental pulmonary embolism and anticoagulant therapy: the impact of clinical context.

BACKGROUND: Anticoagulation for subsegmental pulmonary embolism (SSPE) is controversial. AIM: To assess the impact of clinical context on anticoagulation and outcomes of SSPE. METHODS: We electronically searched computed tomography pulmonary angiogram reports to identify SSPE. We extracted demographic, risk factor, investigations and outcome data from the electronic medical record. We stratified patients according to anticoagulation and no anticoagulation. RESULTS: From 1 January 2017 to 31 December 2019, we identified 166 patients with SSPE in 5827 pulmonary angiogram reports. Of these, 123 (74%) received anticoagulation. Compared with non-anticoagulated patients, such patients had a different clinical context: higher rates of previous venous thromboembolism (11% vs 0%; P = 0.019), more recent surgery (26% vs 9%; P = 0.015), more elevated serum D-dimer (22% vs 5%; P = 0.004), more lung parenchymal abnormalities (76% vs 61%; P = 0.037) and were almost twice as likely to require inpatient care (76% vs 42%; P < 0.001). Such patients also had twice the all-cause mortality at 1 year (32% vs 16%). CONCLUSIONS: SSPE is diagnosed in almost 3% of pulmonary angiograms and is associated with high mortality, regardless of anticoagulation, due to coexistent disease processes rather than SSPE. Anticoagulation appears dominant but markedly affected by the clinical context of risk factors, alternative indications and illness severity. Thus, the controversy is partly artificial because anticoagulation after SSPE is clinically contextual with SSPE as only one of several factors.

Improving the quality of family meeting documentation in the ICU at the end of life.

Objective: Improve documentation quality of end-of-life family meetings in a tertiary intensive care unit (ICU). Design: Before-and-after interventional quality improvement project between October 2018 and February 2020 utilising an electronic pro-forma record. Setting: Australian, University affiliated, mixed medical-surgical 22 bed adult ICU. Participants: Patients who were admitted to the ICU for active management and subsequently died during that ICU admission. We enrolled 50 patients who died before and 50 patients after the introduction of the electronic family meeting pro-forma record. Intervention: Through collaboration with ICU medical and nursing staff, End-of-life Special Interest Group and Clinical Documentation Committee we developed the ICU Family Meeting Discussion Note as an electronic pro-forma record with multiple key fields of entry. Main outcome measures: Patient records were examined for the presence of documented details around patient's admission, family meetings and specific elements surrounding the patient's death. Results: The introduction of a pro-forma record markedly improved the quality of documentation of end-of-life care related family meetings. Documentation increased in recording hospital admission date/time (6% vs 84%), meeting location (14% vs 70%), the reason patients were absent from the meeting (34% vs 72%), the Medical Treatment Decision Maker (MTDM) (10% vs 44%), the patient's resuscitation status (22% vs 54%), and treatment options discussed (78% vs 94%) (p ⩽ 0.005 for all). Conclusion: Introducing an electronic pro-forma record to facilitate family meeting documentation increased the frequency of important recorded information. Further studies are required to assess whether documentation quality improvements are sustainable and whether they affect patient- or relative-centred outcomes.

The pulse volume recorder as a measure of peripheral vascular status in people with diabetes mellitus.

BACKGROUND: Peripheral vascular disease is common in persons with diabetes. There is growing evidence that the vascular contribution to foot disease in diabetes is greater than has previously been realized. METHODS: A cross-sectional study of vascular status in 205 subjects with type 1 and type 2 diabetes mellitus was carried out as part of a larger diabetes assessment study. Palpation of pedal pulses, color spectral waveforms, pulse volume recording, and Doppler ankle-brachial pressure index (ABPI) were recorded bilaterally in all subjects. These modalities were evaluated descriptively, and kappa statistics were used to evaluate agreement between ABPI and pulse volume recording. In addition, visual comparisons between the color spectral waveforms (study gold standard) and pulse volume recordings were also undertaken, and clinical usefulness of pulse volume recording was evaluated. RESULTS: Results of this study identified 15.6% (n = 32) subjects having one or more pedal pulses absent on either foot, 47% (n = 98) an abnormal ABPI (<0.9/>1.30), 7.8% (n = 16) an abnormal monophasic waveform, and 7.3% (n = 15) with an abnormal pulse volume recording. The level of agreement between ABPI and pedal pulse palpation was low at 52.2%, between ABPI and spectral waveforms was low at 58%, and between ABPI and pulse volume recording was also low at 45.3%. When the pulse volume recordings were compared with the color spectral waveforms, however, the level of agreement was high at 91.7%. CONCLUSIONS: Pulse volume recording agrees well with the color spectral waveforms. It can be used with all subjects including those with edema. It is simple, quick, and valuable in a community setting to determine the need for further investigations.