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Query: UMLS:C0034065 (pulmonary embolism)
 14,979 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Excluding or confirming pulmonary embolism remains a diagnostic challenge. In elderly patients pulmonary embolism is associated with substantial co-morbidity and mortality, and many elderly patients with suspected pulmonary embolism are inpatients. The safety and efficacy of the combination of a clinical probability (CDR) and d-dimer test in excluding pulmonary embolism in this group is unclear. We retrospectively analysed data of two prospective studies of consecutive in-and outpatients with suspected pulmonary embolism. The patients were categorized into three age groups: <65 years, 65-75 years and >75 years. The sensitivity, negative predictive value and the proportion of patients with the combination of a non-high CDR score according to Wells (< or = 4) and a normal d-dimer result were calculated for each group. In 747 consecutive patients with suspected pulmonary embolism, sensitivity and negative predictive value of a non-high CDR and a normal d-dimer result in outpatients (n=538) of all age categories (<65 years, 65-75 years and >75 years) were both 100%. These tests were, however, less reliable for inpatients(n=209), irrespective of their age (sensitivity 91% [ CI: 79-98%], negative predictive value 88 % [CI: 74-96%]. The proportion of both in-and outpatients >75 years with a non-high CDR and a normal d-dimer concentration was only 14%, whereas this was 22% in patients 65-75 years and 41% among in-and outpatients <65 years, respectively. In elderly outpatients the combination of a non-high CDR and a normal d-dimer result is a safe strategy to rule out pulmonary embolism. However, in inpatients this algorithm is not reliable to safely exclude pulmonary embolism. In addition, the proportion of patients >65 years in which this strategy excludes pulmonary embolism is markedly lower compared to younger patients.
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PMID:Diagnostic strategy using a modified clinical decision rule and D-dimer test to rule out pulmonary embolism in elderly in- and outpatients. 1611 5

Background and Objectives: Adherence to guidelines by physicians of an emergency department (ED) depends on many factors: guideline and environmental factors; patient and practitioner characteristics; the social-political context. We focused on the impact of the environmental influence and of the patients' characteristics on adherence to the guidelines. It is our intention to demonstrate how environmental factors such as ED organization more affect adherence to guidelines than the patient's clinical presentation, even in a clinically insidious disease such as pulmonary embolism (PE). Materials and Methods: A single-center observational study was carried out on all patients who were seen at our Department of Emergency and Acceptance from 1 January to 31 December 2017 for PE. For the assessment of adherence to guidelines, we used the European guidelines 2014 and analyzed adherence to the correct use of clinical decision rule (CDR as Wells, Geneva, and YEARS); the correct initiation of heparin therapy; and the management of patients at high risk for short-term mortality. The primary endpoint of our study was to determine whether adherence to the guidelines as a whole depends on patients' management in a holding area. The secondary objective was to determine whether adherence to the guidelines depended on patient characteristics such as the presence of typical symptoms or severe clinical features (massive pulmonary embolism; organ damage). Results: There were significant differences between patients who passed through OBI and those who did not, in terms of both administration of heparin therapy alone (p = 0.007) and the composite endpoints of heparin therapy initiation and observation/monitoring (p = 0.004), as indicated by the guidelines. For the subgroups of patients with massive PE, organ damage, and typical symptoms, there was no greater adherence to the decision making, administration of heparin therapy alone, and the endpoints of heparin therapy initiation and guideline-based observation/monitoring. Conclusion: Patients managed in an ED holding area were managed more in accordance with the guidelines than those who were managed only in the visiting ED rooms and directly hospitalized from there.
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PMID:Impact of ED Organization with a Holding Area and a Dedicated Team on the Adherence to International Guidelines for Patients with Acute Pulmonary Embolism: Experience of an Emergency Department Organized in Areas of Intensity of Care. 3298 44