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A simplified risk prediction model for patients presenting with acute pulmonary embolism
Clinical question: Is there a simplified risk prediction model to identify those with low risk pulmonary embolism (PE) who can be treated as outpatients?
Background: Existing prognostic models for patients with acute PE are dependent on comorbidities, which can be challenging to use in a scoring system. Models that make use of acute clinical variables to predict morbidity or mortality may be of greater clinical utility.
Study design: Retrospective chart review with derivation and validation analysis.
Setting: Tertiary care hospital in Chennai, India.
Synopsis: The authors identified 400 patients with acute PE who met inclusion criteria. Using logistic regression and readily accessible clinical variables previously shown to be associated with acute PE mortality, the authors created the HOPPE prediction score: heart rate, PaO2, systolic blood pressure, diastolic blood pressure, and ECG score. Each variable was classified into three groups and assigned a point value that could be summed to a cumulative 30-day mortality risk score. In the derivation and validation cohorts, the low, intermediate, and high HOPPE scores were associated with a 30-day mortality of 0%, 7.5-8.5%, and 18.2-18.8%, respectively, with similar trends for secondary outcomes including right ventricular dysfunction, nonfatal cardiogenic shock, and cardiorespiratory arrest.
In comparison with the previously validated PESI score, the HOPPE score had significantly higher sensitivity, specificity, and discriminative power. The conclusions from this study were limited by its single institutional design.
Bottom line: The HOPPE score provides a risk assessment tool to identify those patients with acute PE who are at lowest and highest risk for morbidity and mortality.
Citation: Subramanian M et al. Derivation and validation of a novel prediction model to identify low-risk patients with acute pulmonary embolism. Am J Cardiol. 2017;120(4):676-81.
Dr. Pizza is a hospitalist, Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.
Clinical question: Is there a simplified risk prediction model to identify those with low risk pulmonary embolism (PE) who can be treated as outpatients?
Background: Existing prognostic models for patients with acute PE are dependent on comorbidities, which can be challenging to use in a scoring system. Models that make use of acute clinical variables to predict morbidity or mortality may be of greater clinical utility.
Study design: Retrospective chart review with derivation and validation analysis.
Setting: Tertiary care hospital in Chennai, India.
Synopsis: The authors identified 400 patients with acute PE who met inclusion criteria. Using logistic regression and readily accessible clinical variables previously shown to be associated with acute PE mortality, the authors created the HOPPE prediction score: heart rate, PaO2, systolic blood pressure, diastolic blood pressure, and ECG score. Each variable was classified into three groups and assigned a point value that could be summed to a cumulative 30-day mortality risk score. In the derivation and validation cohorts, the low, intermediate, and high HOPPE scores were associated with a 30-day mortality of 0%, 7.5-8.5%, and 18.2-18.8%, respectively, with similar trends for secondary outcomes including right ventricular dysfunction, nonfatal cardiogenic shock, and cardiorespiratory arrest.
In comparison with the previously validated PESI score, the HOPPE score had significantly higher sensitivity, specificity, and discriminative power. The conclusions from this study were limited by its single institutional design.
Bottom line: The HOPPE score provides a risk assessment tool to identify those patients with acute PE who are at lowest and highest risk for morbidity and mortality.
Citation: Subramanian M et al. Derivation and validation of a novel prediction model to identify low-risk patients with acute pulmonary embolism. Am J Cardiol. 2017;120(4):676-81.
Dr. Pizza is a hospitalist, Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.
Clinical question: Is there a simplified risk prediction model to identify those with low risk pulmonary embolism (PE) who can be treated as outpatients?
Background: Existing prognostic models for patients with acute PE are dependent on comorbidities, which can be challenging to use in a scoring system. Models that make use of acute clinical variables to predict morbidity or mortality may be of greater clinical utility.
Study design: Retrospective chart review with derivation and validation analysis.
Setting: Tertiary care hospital in Chennai, India.
Synopsis: The authors identified 400 patients with acute PE who met inclusion criteria. Using logistic regression and readily accessible clinical variables previously shown to be associated with acute PE mortality, the authors created the HOPPE prediction score: heart rate, PaO2, systolic blood pressure, diastolic blood pressure, and ECG score. Each variable was classified into three groups and assigned a point value that could be summed to a cumulative 30-day mortality risk score. In the derivation and validation cohorts, the low, intermediate, and high HOPPE scores were associated with a 30-day mortality of 0%, 7.5-8.5%, and 18.2-18.8%, respectively, with similar trends for secondary outcomes including right ventricular dysfunction, nonfatal cardiogenic shock, and cardiorespiratory arrest.
In comparison with the previously validated PESI score, the HOPPE score had significantly higher sensitivity, specificity, and discriminative power. The conclusions from this study were limited by its single institutional design.
Bottom line: The HOPPE score provides a risk assessment tool to identify those patients with acute PE who are at lowest and highest risk for morbidity and mortality.
Citation: Subramanian M et al. Derivation and validation of a novel prediction model to identify low-risk patients with acute pulmonary embolism. Am J Cardiol. 2017;120(4):676-81.
Dr. Pizza is a hospitalist, Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.
Diagnostic delays, morbidity, and epidural abscesses
Clinical question: What is the frequency of diagnostic delays in epidural abscesses, and what factors may contribute to these delays?
Background: Diagnostic evaluation of back pain can be challenging. Missed diagnosis of serious conditions such as epidural abscesses can lead to significant morbidity.
Setting: Veterans Affairs Electronic Medical Record database from more than 1,700 VA outpatient and inpatient facilities in the United States.
Synopsis: Of the 119 patients with a new diagnosis of spinal epidural abscess, 55.5% were felt to have experienced a diagnostic error, defined by the study authors as a missed opportunity to evaluate a red flag (e.g. weight loss, neurologic deficit, fever) in a timely or appropriate manner. There was a significant difference in the time to diagnosis between patients with and without a diagnostic error (4 versus 12 days, P less than .01). Of those cases involving diagnostic error, 60.6% were felt to have resulted in serious patient harm and 12.1% in patient death. The most commonly missed red flags were fever, focal neurological deficits, and signs of active infection.
Based on these findings, the authors suggest that future intervention focus on improving information gathering during patient-physician encounter and physician education about existing guidelines.
The limitations of this study include its use of data from a single health system, and the employment of chart reviews instead of a root cause analysis based on provider and patient interviews.
Bottom line: A delay in diagnosis resulting in patient harm or death may occur frequently in cases of epidural abscesses. Further work on targeted interventions to reduce error and prevent harm are needed.
Citation: Bhise V, Meyer A, Singh H, et al. Diagnosis of spinal epidural abscesses in the era of electronic health records. Am J Med. 2017;130(8):975-81.
Dr. Pizza is a hospitalist, Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.
Clinical question: What is the frequency of diagnostic delays in epidural abscesses, and what factors may contribute to these delays?
Background: Diagnostic evaluation of back pain can be challenging. Missed diagnosis of serious conditions such as epidural abscesses can lead to significant morbidity.
Setting: Veterans Affairs Electronic Medical Record database from more than 1,700 VA outpatient and inpatient facilities in the United States.
Synopsis: Of the 119 patients with a new diagnosis of spinal epidural abscess, 55.5% were felt to have experienced a diagnostic error, defined by the study authors as a missed opportunity to evaluate a red flag (e.g. weight loss, neurologic deficit, fever) in a timely or appropriate manner. There was a significant difference in the time to diagnosis between patients with and without a diagnostic error (4 versus 12 days, P less than .01). Of those cases involving diagnostic error, 60.6% were felt to have resulted in serious patient harm and 12.1% in patient death. The most commonly missed red flags were fever, focal neurological deficits, and signs of active infection.
Based on these findings, the authors suggest that future intervention focus on improving information gathering during patient-physician encounter and physician education about existing guidelines.
The limitations of this study include its use of data from a single health system, and the employment of chart reviews instead of a root cause analysis based on provider and patient interviews.
Bottom line: A delay in diagnosis resulting in patient harm or death may occur frequently in cases of epidural abscesses. Further work on targeted interventions to reduce error and prevent harm are needed.
Citation: Bhise V, Meyer A, Singh H, et al. Diagnosis of spinal epidural abscesses in the era of electronic health records. Am J Med. 2017;130(8):975-81.
Dr. Pizza is a hospitalist, Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.
Clinical question: What is the frequency of diagnostic delays in epidural abscesses, and what factors may contribute to these delays?
Background: Diagnostic evaluation of back pain can be challenging. Missed diagnosis of serious conditions such as epidural abscesses can lead to significant morbidity.
Setting: Veterans Affairs Electronic Medical Record database from more than 1,700 VA outpatient and inpatient facilities in the United States.
Synopsis: Of the 119 patients with a new diagnosis of spinal epidural abscess, 55.5% were felt to have experienced a diagnostic error, defined by the study authors as a missed opportunity to evaluate a red flag (e.g. weight loss, neurologic deficit, fever) in a timely or appropriate manner. There was a significant difference in the time to diagnosis between patients with and without a diagnostic error (4 versus 12 days, P less than .01). Of those cases involving diagnostic error, 60.6% were felt to have resulted in serious patient harm and 12.1% in patient death. The most commonly missed red flags were fever, focal neurological deficits, and signs of active infection.
Based on these findings, the authors suggest that future intervention focus on improving information gathering during patient-physician encounter and physician education about existing guidelines.
The limitations of this study include its use of data from a single health system, and the employment of chart reviews instead of a root cause analysis based on provider and patient interviews.
Bottom line: A delay in diagnosis resulting in patient harm or death may occur frequently in cases of epidural abscesses. Further work on targeted interventions to reduce error and prevent harm are needed.
Citation: Bhise V, Meyer A, Singh H, et al. Diagnosis of spinal epidural abscesses in the era of electronic health records. Am J Med. 2017;130(8):975-81.
Dr. Pizza is a hospitalist, Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.
Supplemental oxygen use for suspected myocardial infarction without hypoxemia
Background: Clinical guidelines recommend supplemental oxygen in patients with suspected acute myocardial infarction but data to support its use in patients without hypoxemia are limited.
Study design: Open-label, registry based randomized clinical trial.
Setting: Thirty-five hospitals in Sweden with acute cardiac care facilities.
Synopsis: Authors included 6,629 patients aged 30 and older who presented with symptoms suggestive of myocardial infarction. Patients with oxygen saturations 90% or greater were enrolled in the study and randomly assigned to either 6 liters per minute of face mask oxygen for 6-12 hours or ambient air. Median oxygen saturation was 99% in the treatment group and 97% in the ambient air group (P less than .0001). In an intention-to-treat model, 1 year after randomization there was no significant difference in all-cause mortality between the oxygen (5.0%) and ambient air (5.1%) groups (P = .80). There was no difference in the rate of rehospitalization with myocardial infarction or the composite endpoint of all-cause mortality and rehospitalizations for myocardial infarction at 30 days and 1 year. Limitations of this study include lower power than anticipated since calculations were based on a higher mortality rate than observed in this study, and the open-label protocol.
Bottom line: In patients who present with a suspected myocardial infarction without hypoxemia, oxygen therapy is not associated with improved all-cause mortality or decreased rehospitalizations for myocardial infarction.
Citation: Hofmann R, Jernberg T, Erlinge D, et al. Oxygen therapy in suspected acute myocardial infarction. N Engl J Med. 2017;377:1240-9.
Dr. Gala is a hospitalist, Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.
Background: Clinical guidelines recommend supplemental oxygen in patients with suspected acute myocardial infarction but data to support its use in patients without hypoxemia are limited.
Study design: Open-label, registry based randomized clinical trial.
Setting: Thirty-five hospitals in Sweden with acute cardiac care facilities.
Synopsis: Authors included 6,629 patients aged 30 and older who presented with symptoms suggestive of myocardial infarction. Patients with oxygen saturations 90% or greater were enrolled in the study and randomly assigned to either 6 liters per minute of face mask oxygen for 6-12 hours or ambient air. Median oxygen saturation was 99% in the treatment group and 97% in the ambient air group (P less than .0001). In an intention-to-treat model, 1 year after randomization there was no significant difference in all-cause mortality between the oxygen (5.0%) and ambient air (5.1%) groups (P = .80). There was no difference in the rate of rehospitalization with myocardial infarction or the composite endpoint of all-cause mortality and rehospitalizations for myocardial infarction at 30 days and 1 year. Limitations of this study include lower power than anticipated since calculations were based on a higher mortality rate than observed in this study, and the open-label protocol.
Bottom line: In patients who present with a suspected myocardial infarction without hypoxemia, oxygen therapy is not associated with improved all-cause mortality or decreased rehospitalizations for myocardial infarction.
Citation: Hofmann R, Jernberg T, Erlinge D, et al. Oxygen therapy in suspected acute myocardial infarction. N Engl J Med. 2017;377:1240-9.
Dr. Gala is a hospitalist, Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.
Background: Clinical guidelines recommend supplemental oxygen in patients with suspected acute myocardial infarction but data to support its use in patients without hypoxemia are limited.
Study design: Open-label, registry based randomized clinical trial.
Setting: Thirty-five hospitals in Sweden with acute cardiac care facilities.
Synopsis: Authors included 6,629 patients aged 30 and older who presented with symptoms suggestive of myocardial infarction. Patients with oxygen saturations 90% or greater were enrolled in the study and randomly assigned to either 6 liters per minute of face mask oxygen for 6-12 hours or ambient air. Median oxygen saturation was 99% in the treatment group and 97% in the ambient air group (P less than .0001). In an intention-to-treat model, 1 year after randomization there was no significant difference in all-cause mortality between the oxygen (5.0%) and ambient air (5.1%) groups (P = .80). There was no difference in the rate of rehospitalization with myocardial infarction or the composite endpoint of all-cause mortality and rehospitalizations for myocardial infarction at 30 days and 1 year. Limitations of this study include lower power than anticipated since calculations were based on a higher mortality rate than observed in this study, and the open-label protocol.
Bottom line: In patients who present with a suspected myocardial infarction without hypoxemia, oxygen therapy is not associated with improved all-cause mortality or decreased rehospitalizations for myocardial infarction.
Citation: Hofmann R, Jernberg T, Erlinge D, et al. Oxygen therapy in suspected acute myocardial infarction. N Engl J Med. 2017;377:1240-9.
Dr. Gala is a hospitalist, Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.