Related Articles

The Mortality Benefit Threshold for Patients with Suspected Pulmonary Embolism.

Acad Emerg Med. 2012 Sep;19(9):E1109-E1113

Authors: Pines JM, Lessler AL, Ward MJ, Mark Courtney D

Abstract
ACADEMIC EMERGENCY MEDICINE 2012; 19:1109-1113 © 2012 by the Society for Academic Emergency Medicine ABSTRACT: Objectives:  The mortality benefit for pulmonary embolism (PE) is the difference in mortality between treated and untreated patients. The mortality benefit threshold is the mortality benefit above which testing for a condition should be initiated and below which it should not. To illustrate this concept, the authors developed a decision model to estimate the mortality benefit threshold at several pretest probabilities for low-risk emergency department (ED) patients with possible PE and compare those thresholds with contemporary management of PE in the United States and what is known and not known about treatment benefits with anticoagulation. Methods:  The authors built a decision model of a 25-year-old female with suspected PE. Model inputs were obtained from the literature or clinical judgment when data were unavailable. One-way sensitivity analysis was used to derive the mortality benefit threshold at several fixed pretest probabilities, and two-way sensitivity analysis was used to determine drivers of the mortality benefit threshold. Results:  At a 15% pretest probability, the mortality benefit threshold was 3.7%; at 10% it was 5.2%; at 5% it was 9.8%; at 2% it was 23.5%; at 1% it was 46.3%; and at 0.5% it was 92.1%. In two-way sensitivity analyses, D-dimer specificity, CT angiography (CTA)/CT venography (CTV) sensitivity, annual cancer risk, probability of death from renal failure, and probability of major bleeding were major model drivers. Conclusions:  The mortality benefit threshold for initiating PE testing is very high at low pretest probabilities of PE, which should be considered by clinicians in their diagnostic approach to PE in the ED. The mortality benefit threshold is a novel way of exploring the benefits and risks of ED-based testing, particularly in situations like PE where testing (i.e., CT use) carries real risks and the benefits of treatment are uncertain.

PMID: 22978741 [PubMed - as supplied by publisher]

Inflammatory Biomarkers and Comorbidities in Chronic Obstructive Pulmonary Disease.

Am J Respir Crit Care Med. 2012 Sep 13;

Authors: Thomsen M, Dahl M, Lange P, Vestbo J, Nordestgaard BG

Abstract
RATIONALE: Patients with chronic obstructive pulmonary disease (COPD) have evidence of systemic inflammation that may be implicated in the development of comorbidities. OBJECTIVES: To test the hypothesis that elevated levels of three inflammatory biomarkers are associated with increased risk of comorbidities in COPD. METHODS: We examined 8656 COPD patients from two large Danish population studies and during a median five years follow-up recorded hospital admissions due to major comorbidities as endpoints. MEASUREMENTS AND MAIN RESULTS: We measured baseline C-reactive protein (CRP), fibrinogen, and leukocyte count, and recorded admissions due to ischemic heart disease, myocardial infarction, heart failure, type II diabetes, lung cancer, pneumonia, pulmonary embolism, hip fracture, and depression for all participants. Multifactorially adjusted risk of ischemic heart disease was increased by a factor of 2.19(95%confidence interval:1.48-3.23) in individuals with three biomarkers elevated (CRP above 3 mg per liter, fibrinogen above 14 μmol per liter, and leukocyte count above 9 x109 per liter) versus individuals with all three biomarkers at or below these limits. Corresponding hazard ratios were 2.32(1.34-4.04) for myocardial infarction, 2.63(1.71-4.04) for heart failure, 3.54(2.03-6.19) for diabetes, 4.00(2.12-7.54) for lung cancer, and 2.71(2.03-3.63) for pneumonia. There were no consistent differences in risk of pulmonary embolism, hip fracture, or depression as a function of these three biomarkers. CONCLUSIONS: Simultaneously elevated levels of CRP, fibrinogen, and leukocyte count are associated with a 2 to 4-fold increased risk of major comorbidities in COPD. These biomarkers may be an additional tool for clinicians to conduct stratified management of comorbidities in COPD.

PMID: 22983959 [PubMed - as supplied by publisher]

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Background: The routine use of multidetector computed tomography has led to increased detection of unsuspected pulmonary embolism (UPE), with questionable benefit for diagnosis and treatment. Objective: The purpose of this work was to compare the clinical characteristics and prognosis of patients with UPE to patients with suspected PE (SPE).

Methods: We retrospectively reviewed the charts of patients diagnosed with PE in a community-based university hospital between the years 2002 and 2007. UPE was defined as PE detected on CT scans performed for indications other than suspicion of PE. We compared patients with UPE to patients with SPE for differences in clinical features, electrocardiogram, imaging and echocardiographic findings. We also assessed the long-term outcomes using electronic patient records.

Results: Of 500 patients with PE, 408 had SPE and 92 had UPE. Patients with UPE were similar to patients with SPE regarding age and sex distribution. Malignancy was more prevalent in UPE patients (39 vs. 23%, p < 0.0068). UPE patients had significantly less tachypnea (37 vs. 57%, p = 0.0005), dyspnea (47 vs. 87%, p < 0.0001), chest pain (19 vs. 42%, p < 0.0001) and hypoxemia (36 vs. 55%, p = 0.0011). Mortality was higher in UPE patients (70.3 vs. 53%, p = 0.0029). The hazard ratio after adjustment for confounders including age, sex and malignancy was 1.546 (95% CI: 1.139-2.099, p = 0.0052).

Conclusions: We suggest that UPE is more prevalent in patients with a malignancy and is associated with higher mortality despite a less severe clinical presentation. UPE may be a marker of poor prognosis.