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Thromboprophylaxis patterns, risk factors, and outcomes of care in the medically ill patient population.

Thromb Res. 2013 Aug 28;

Authors: Mahan CE, Fisher MD, Mills RM, Fields LE, Stephenson JJ, Fu AC, Spyropoulos AC

Abstract
INTRODUCTION: Medically ill, hospitalized patients are at increased risk for venous thromboembolism (VTE) after discharge. This study aimed to examine thromboprophylaxis patterns, risk factors, and post-discharge outcomes.
METHODS: This was a retrospective claims analysis involving administrative claims data and in-patient data abstracted from a sample of hospital charts. Patients aged ≥40years hospitalized for ≥2days for nonsurgical reasons between 2005 and 2009 were included. Hospital chart data were abstracted for a random sample of patients without evidence of anticoagulant use at 30days post-discharge. The combined data determined whether in-patient thromboprophylaxis (anticoagulant or mechanical prophylaxis) reduces risk of VTE at 90days post-discharge. Hazard ratios (HR) and odds ratios (OR) were calculated using Cox proportional hazard models and logistic regression.
RESULTS: Of 141,628 patients in the claims analysis, 3.9% received anticoagulants (3.6% warfarin). VTE, rehospitalization, and mortality rates were 1.9%, 17.2%, and 6.2%, respectively. The strongest predictors of post-discharge VTE were history of VTE (HR=4.0, 95% confidence interval [CI]: 3.3-4.8), and rehospitalization (HR=3.9, 95% CI: 3.6-4.3). Of 504 medical charts, 209 (41.5%) reported in-patient thromboprophylaxis. There was no statistically significant difference in post-discharge VTE rates between patients who did and did not receive in-patient thromboprophylaxis. All-cause mortality was greater among patients without use of VTE prophylaxis.
CONCLUSION: Utilization rates of in-hospital and post-discharge VTE prophylaxis were low. In-hospital VTE prophylaxis did not reduce the risk of post-discharge VTE in the absence of post-discharge anticoagulation. Combined in-patient and post-discharge thromboprophylaxis lowered the odds of short-term, all-cause post-discharge mortality.

PMID: 24080150 [PubMed - as supplied by publisher]

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Prediction scores do not correlate with clinically adjudicated categories of pulmonary embolism in critically ill patients.

Can Respir J. 2013 Sep 30;

Authors: Katsios C, Donadini M, Meade M, Mehta S, Hall R, Granton J, Kutsogiannis J, Dodek P, Heels-Ansdell D, McIntyre L, Vlahakis N, Muscedere J, Friedrich J, Fowler R, Skrobik Y, Albert M, Cox M, Klinger J, Nates J, Bersten A, Doig C, Zytaruk N, Crowther M, Cook DJ

PMID: 24083302 [PubMed - as supplied by publisher]

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Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism.

Chest. 2013 Oct 3;

Authors: Nazerian P, Vanni S, Volpicelli G, Gigli C, Zanobetti M, Bartolucci M, Ciavattone A, Lamorte A, Veltri A, Fabbri A, Grifoni S

Abstract
ABSTRACT BACKGROUND: Presenting signs and symptoms of pulmonary embolism (PE) are non-specific, favoring a large use of second-line diagnostic tests such as multi-detector computed tomography pulmonary angiography (MCTPA), thus exposing patients to high-dose radiation and to potential serious complications. We investigated the diagnostic performance of multiorgan ultrasonography (lung, heart and leg veins ultrasonography) and if multiorgan ultrasonography combined to Wells score and D-dimer could safely reduce MCTPA tests.
METHODS: Consecutive adult patients suspected of PE and with a Wells score >4 or a positive D-dimer were prospectively enrolled in three emergency departments. Final diagnosis was obtained with MCTPA. Multiorgan ultrasonography was performed before MCTPA and considered diagnostic for PE if one or more subpleural infarcts, right ventricular dilatation or deep vein thrombosis were detected. If multiorgan ultrasonography was negative for PE, an alternative ultrasonography diagnosis was searched for. Accuracies of each single-organ and multiorgan ultrasonography were calculated.
RESULTS: PE was diagnosed in 110 (30.8%) out of 357 enrolled patients. Multiorgan ultrasonography yielded a sensitivity of 90% and a specificity of 86.2%, lung ultrasonography of 60.9% and 95.9%, heart ultrasonography of 32.7% and 90.9% and vein ultrasonography of 52.7% and 97.6% respectively. Among the 132 (37%) patients with multiorgan ultrasonography negative for PE plus an alternative ultrasonographic diagnosis or plus a negative D-dimer, no patients had PE as final diagnosis.
CONCLUSIONS: Multiorgan ultrasonography is more sensitive than single-organ ultrasonography, increases the accuracy of clinical pre-test probability estimation in patients with suspected PE and may safely reduce the MCTPA burden. (ClinicalTrials.gov number, NCT01635257).

PMID: 24092475 [PubMed - as supplied by publisher]

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Reliability of on-call radiology residents' interpretation of 64-slice CT pulmonary angiography for the detection of pulmonary embolism.

Acta Radiol. 2013 Oct 3;

Authors: Joshi R, Wu K, Kaicker J, Choudur H

Abstract
BACKGROUND: Computed tomography (CT) angiography for pulmonary embolism (PE) is the present standard for diagnosing PE. In many teaching hospitals, radiology residents are the first to review the case and to make an initial interpretation of the images. Accurate diagnosis of PE is crucial, especially in the emergency care setting.
PURPOSE: To evaluate the discrepancies between resident and staff interpretations of 64-slice CT angiogram for PE.
MATERIAL AND METHODS: Discrepancies between the preliminary reports by the on-call radiology resident were compared to the final report by the staff radiologist in 215 consecutive cases of 64-slice CT angiogram performed for PE, from May 2005 to March 2008.
RESULTS: Discrepancies were noted in 25 of the 215 studies (11.6%). These residents' discrepancies consisted of three false-positive, four false-negative, and 18 equivocal cases. There was a decrease in the discrepancy rate from the second year to the fifth year of training by approximately 60%.
CONCLUSION: The rate of discrepancy fell steeply between the second and fifth year of the residents training from 18.5% to 6.9%. Our study suggests that it is reasonable to have on-call radiology residents perform the preliminary interpretations of 64-slice CT for PE studies.

PMID: 24092761 [PubMed - as supplied by publisher]