Comparisons of clinical scoring systems among suspected pulmonary embolism patients presenting to emergency department
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ABSTRACT:
SUBMITTER: Tang L
PROVIDER: S-EPMC11335811 | biostudies-literature | 2024 Aug
REPOSITORIES: biostudies-literature
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Project description:Around 42,000 children suffer from severe sepsis each year in the US alone, resulting in significant morbidity, mortality and billion dollar expenditures in the US healthcare system. Sepsis recognition is a clinical challenge in children. Biomarkers are needed to tailor appropriate antimicrobial therapies and improve risk stratification. The goal of this study was to determine if gene expression profiles from peripheral blood were associated with pathogen type and sepsis severity in children treated for suspected sepsis.
2020-01-01 | GSE119217 | GEO
Project description:ObjectivePulmonary embolisms (PE) are clinically challenging because of their high morbidity and mortality. This study aimed to create a nomogram to accurately predict the risk of PE in respiratory department patients in order to enhance their medical treatment and management.MethodsThis study utilized a retrospective method to collect information on medical history, complications, specific clinical characteristics, and laboratory biomarker results of suspected PE patients who were admitted to the respiratory department at Affiliated Dongyang Hospital of Wenzhou Medical University between January 2012 and December 2021. This study involved a total of 3,511 patients who were randomly divided into a training group (six parts) and a validation group (four parts) based on a 6:4 ratio. The LASSO regression and multivariate logistic regression were used to develop a scoring model using a nomogram. The performance of the model was evaluated using receiver operating characteristic curve (AUC), calibration curve, and clinical decision curve.ResultsOur research included more than 50 features from 3,511 patients. The nomogram-based scoring model was established using six predictive features including age, smoke, temperature, systolic pressure, D-dimer, and fibrinogen, which achieved AUC values of 0.746 in the training cohort (95% CI 0.720-0.765) and 0.724 in the validation cohort (95% CI 0.695-0.753). The results of the calibration curve revealed a strong consistency between probability predicted by the nomogram and actual probability. The decision curve analysis (DCA) also demonstrated that the nomogram-based scoring model produced a favorable net clinical benefit.ConclusionIn this study, we successfully developed a novel numerical model that can predict the risk of PE in respiratory department patients suspected of PE, which can not only appropriately select PE prevention strategies but also decrease unnecessary computed tomographic pulmonary angiography (CTPA) scans and their adverse effects.
| S-EPMC10229862 | biostudies-literature
Project description:ObjectivesWhile our understanding of coronavirus disease 2019 (COVID-19) has evolved, uncertainty remains regarding utility of previously established pulmonary embolism (PE) screening guidelines in patients with COVID-19. Many studies have investigated the efficacy of D-dimer (DD) screenings for patients with COVID-19 admitted to inpatient services, but few have evaluated patients in the emergency department (ED). The purpose of this study was to investigate utility of DD threshold for PE screening in patients with COVID-19 presenting to the ED.MethodsThis was a retrospective, multicenter cohort including patients presenting to three EDs between March 1, 2020 and February 1, 2021 who tested positive for COVID-19 during ED visit or in 60 days prior to presentation and had DD ordered in ED. Patients were grouped by those who underwent computed tomography pulmonary angiogram (CTPA) to evaluate for PE and those who did not, and descriptive statistics were performed. Those who underwent CTPA were further divided into PE-positive and PE-negative groups. The discriminative ability of DD in predicting PE in patients with COVID-19 was analyzed using the receiver operating characteristic (ROC) curve.ResultsA total of 570 patients with COVID-19 were included in the study, of which 107 underwent CTPA to evaluate for PE. History of diabetes, elevated glucose, elevated lactate dehydrogenase, elevated white blood cell count, elevated platelets, elevated respiratory rate, and lower temperature were associated with increased risk for PE. Compared to those without PE, patients with PE were significantly more likely to be hospitalized (100% vs. 82%, p = 0.020) and admitted to the ICU (64% vs. 24%, p = 0.002). Those with PE had a significantly higher median DD value (21,177 ng/mL) compared to PE-negative group (952 ng/mL, p < 0.001). The ROC curve for DD in predicting PE had an area under the curve of 0.91 (95% confidence interval [0.84, 0.98]). In our study population, the optimal DD threshold for predicting PE was 1815 ng/mL (sensitivity 93% and specificity 80%). A conservative threshold of 1089 ng/mL could be used with sensitivity 100% and specificity 58%.ConclusionDD is often elevated in patients with COVID-19, regardless of PE. While the classically used DD cutoff is 500 ng/mL, our study demonstrated a threshold of 1089 ng/mL safely predicted PE in patients with COVID-19 .
| S-EPMC11255020 | biostudies-literature
Project description:BackgroundIn patients with suspected pulmonary embolism (PE), the literature suggests the overuse of computerized tomography pulmonary angiography (CTPA) and underuse of clinical decision rules before imaging request. This study determined the potential for avoidable CTPA using the modified Wells score (mWS) and D-dimer assay in patients with suspected PE.MethodsThis hospital-based retrospective study analyzed the clinical data of 661 consecutive patients with suspected PE who underwent CTPA in the emergency department of a tertiary hospital for the use of a clinical prediction rule (mWS) and D-dimer assay. The score was calculated retrospectively from the available data in the files of patients who did not have a documented clinical prediction rule. Overuse (avoidable) CTPA was defined as D-dimer negativity and PE unlikely for this study.ResultsOf 661 patients' data examined, clinical prediction rules were documented in 15 (2.3%). In total, 422 patients (63.8%) had required information on modified Wells criteria and D-dimer assays and were included for further analysis. PE on CTPA was present in 22 (5.21%) of PE unlikely (mWS ≤4) and 1 (0.24%) of D-dimer negative patients. Thirty patients (7.11%) met the avoidable CTPA (DD negative+PE unlikely) criteria, and it was significantly associated with dyspnea. The value of sensitivity of avoidable CTPA was 100%, whereas the positive predictive value was 90.3%.ConclusionUnderutilization of clinical prediction rules before prescribing CTPA is common in emergency departments. Therefore, a mandatory policy should be implemented regarding the evaluation of avoidable CTPA imaging to reduce CTPA overuse.
| S-EPMC10063597 | biostudies-literature
Project description: Not available
| S-EPMC8461006 | biostudies-literature
Project description:ObjectivesTo identify which level of D-dimer would allow the safe exclusion of pulmonary embolism (PE) in COVID-19 patients presenting to the emergency department (ED).MethodsThis retrospective study was conducted on the COVID database of Assistance Publique - Hôpitaux de Paris (AP-HP). COVID-19 patients who presented at the ED of AP-HP hospitals between March 1 and May 15, 2020, and had CTPA following D-dimer dosage within 48h of presentation were included. The D-dimer sensitivity, specificity, and positive and negative predictive values were calculated for different D-dimer thresholds, as well as the false-negative and failure rates, and the number of CTPAs potentially avoided.ResultsA total of 781 patients (mean age 62.0 years, 53.8% men) with positive RT-PCR for SARS-Cov-2 were included and 60 of them (7.7%) had CTPA-confirmed PE. Their median D-dimer level was significantly higher than that of patients without PE (4,013 vs 1,198 ng·mL-1, p < 0.001). Using 500 ng·mL-1, or an age-adjusted cut-off for patients > 50 years, the sensitivity and the NPV were above 90%. With these thresholds, 17.1% and 31.5% of CTPAs could have been avoided, respectively. Four of the 178 patients who had a D-dimer below the age-adjusted cutoff had PE, leading to an acceptable failure rate of 2.2%. Using higher D-dimer cut-offs could have avoided more CTPAs, but would have lowered the sensitivity and increased the failure rate.ConclusionThe same D-Dimer thresholds as those validated in non-COVID outpatients should be used to safely rule out PE.Key points• The median D-dimer level was significantly higher in COVID-19 patients with PE as compared to those without PE (4,013 ng·mL-1 vs 1,198 ng·mL-1 respectively, p < 0.001). • Using 500 ng·mL-1, or an age-adjusted D-dimer cut-off to exclude pulmonary embolism, the sensitivity and negative predictive value were above 90%. • Higher cut-offs would lead to a reduction in the sensitivity below 85% and an increase in the failure rate, especially for patients under 50 years.
| S-EPMC8739682 | biostudies-literature
Project description:The diagnosis of pulmonary embolism (PE) in the emergency department is challenging due to the wide range of non-specific symptoms, lack of clinical diagnostic criteria, and imperfect investigations. Various scoring systems exist in an attempt to limit unnecessary investigations in those with low risk of PE. Following a baseline audit and subsequent PDSA cycles we implemented a flowchart for use in patients suspected of pulmonary embolism encouraging the correct use of the Wells Score and Pulmonary Embolism Rule out Criteria (PERC). The standard used for comparison was based on the NICE guidelines for diagnosis of PE with the addition that PERC could also be used if appropriate. Data was collected over four week periods before and after the introduction of our flowchart in two emergency departments in Melbourne. We aimed to increase documentation of pre-test probability, reduce inappropriate investigations, and increase the use of interim parenteral anticoagulation where there was a delay to imaging. Results showed an increase in the documentation of pre-test probability and the proportion of investigations requested that were inappropriate was reduced. The percentage of inappropriate d-dimers was reduced from 36% to 24%; the percentage of inappropriate CTPAs was reduced from 34% to 10%; and the percentage of inappropriate V/Q scans was reduced from 42% to 14%. Implementation of a simple diagnostic algorithm led to an increase in documentation of pre-test probability and a reduction in inappropriate and unnecessary investigations. This intervention may be applicable to other emergency departments where similar issues in diagnosing pulmonary embolism exist.
| S-EPMC4752702 | biostudies-literature
Project description:ObjectiveWe aimed to compare the modified National Early Warning Score (mNEWS), quick Sequential Organ Failure Assessment (qSOFA) score, modified Systemic Inflammatory Response Syndrome (mSIRS) score, and modified Search Out Severity (mSOS) score in predicting mortality and sepsis among patients suspected of first observed infections in the emergency department. The modified scores were created by removing variables for simplicity.MethodsThis was a prospective cohort study that enrolled adult patients presenting at the emergency department with signs and symptoms suggesting infection. The mNEWS, qSOFA score, mSIRS score, and mSOS score were calculated using triage data. The SOFA score was a reference standard for sepsis diagnosis. All patients were monitored for up to 30 days after the initial visit to measure each scoring system's ability to predict 30-day mortality and sepsis.ResultsThere were 260 patients included in the study. The 30-day mortality prediction with mNEWS ≥5 had the highest sensitivity (91.18%). The highest area under the receiver operating characteristic curve (AUC) for the 30-day mortality prediction was mNEWS (0.607), followed by qSOFA (0.605), mSOS (0.550), and mSIRS (0.423). The sepsis prediction with mNEWS ≥5 had the highest sensitivity (96.48%). The highest AUC for the sepsis prediction was also mNEWS (0.685), followed by qSOFA (0.605), mSOS (0.480), and mSIRS (0.477).ConclusionmNEWS was an acceptable scoring system screening tool for predicting mortality and sepsis in patients with a suspected infection.
| S-EPMC8743683 | biostudies-literature
Project description:IntroductionMany emergency department (ED) patients with acute pulmonary embolism (PE) who meet low-risk criteria may be eligible for a short length of stay (LOS) (<24 hours), with expedited discharge home either directly from the ED or after a brief observation or hospitalization. We describe the association between expedited discharge and site of discharge on care satisfaction and quality of life (QOL) among patients with low-risk PE (PE Severity Index [PESI] Classes I-III).MethodsThis phone survey was conducted from September 2014 through April 2015 as part of a retrospective cohort study across 21 community EDs in Northern California. We surveyed low-risk patients with acute PE, treated predominantly with enoxaparin bridging and warfarin. All eligible patients were called 2-8 weeks after their index ED visit. PE-specific, patient-satisfaction questions addressed overall care, discharge instruction clarity, and LOS. We scored physical and mental QOL using a modified version of the validated Short Form Health Survey. Satisfaction and QOL were compared by LOS. For those with expedited discharge, we compared responses by site of discharge: ED vs. hospital, which included ED-based observation units. We used chi-square and Wilcoxon rank-sum tests as indicated.ResultsSurvey response rate was 82.3% (424 of 515 eligible patients). Median age of respondents was 64 years; 47.4% were male. Of the 145 patients (34.2%) with a LOS<24 hours, 65 (44.8%) were discharged home from the ED. Of all patients, 89.6% were satisfied with their overall care and 94.1% found instructions clear. Sixty-six percent were satisfied with their LOS, whereas 17.5% would have preferred a shorter LOS and 16.5% a longer LOS. There were no significant differences in satisfaction between patients with LOS<24 hours vs. ≥24 hours (p>0.13 for all). Physical QOL scores were significantly higher for expedited-discharge patients (p=0.01). Patients with expedited discharge home from the ED vs. the hospital had no significant difference in satisfaction (p>0.20 for all) or QOL (p>0.19 for all).ConclusionED patients with low-risk PE reported high satisfaction with their care in follow-up surveys. Expedited discharge (<24 hours) and site of discharge were not associated with differences in patient satisfaction.
| S-EPMC6225929 | biostudies-literature
Project description:Introduction: Several strategies have been devised to safely limit the use of thoracic imaging in patients suspected of pulmonary embolism (PE). However, they are based on different rules for clinical probability (CP) assessment, rendering their combination difficult. The four-level pulmonary embolism probability score (4PEPS) allows the combination of all other strategies using a single CP assessment. Methods and analysis: Pragmatic cluster-randomized trial in 20 EDs. Patients with suspected PE will be included and followed for 90 days (number of patients to be included: 2560, 1280 in each arm). Ten centers will be allocated to the control group where physicians will be free to do as they see fit but they will be given the recommendation to apply a validated strategy. Ten centers will be allocated to the interventional group where the physicians will be given the recommendation to apply the 4PEPS strategy. The primary objective will be to demonstrate that the application of the 4PEPS strategy by the emergency physicians, in comparison to current practices, (i) does not increase the risk of serious events related to diagnostic strategies and (ii) significantly reduces the use of thoracic imaging. Ethics and dissemination: The study will be submitted for approval to an institutional ethics review board for all participating centers. If successful, the SPEED&PEPS trial will have an important impact for patients suspected of PE limiting their irradiation and for public health in substantial savings in terms of the direct cost of diagnostic investigations and the indirect cost of hospitalizations due to waiting times or delayed harmful effects. Funding: This work is funded by a French Public Health grant (PREPS-N 2019). The funding source plays no role in the study design, data collection, analysis, interpretation or the writing of the manuscript. Trial registration: ongoing. Trial status: not started.
| S-EPMC9777430 | biostudies-literature