Independent factors associated with pneumonia among hospitalized patients with acute exacerbations of chronic obstructive pulmonary disease.

Background & objectives: Thyrotoxic periodic paralysis (TPP) is an endocrine emergency presenting with acute-onset flaccid paralysis in a patient having thyrotoxicosis accompanied by hypokalaemia. This study was conducted to evaluate the clinical profile of patients with TPP presenting to three centres in India.
Methods: This retrospective, observational study was conducted at three tertiary care Armed Forces medical centres, located at Lucknow, Kolkata and Delhi. The history, clinical features, treatment details and outcomes were evaluated. 
Results: Of the 244 patients with thyrotoxicosis, 15 were diagnosed with TPP and included in the study. These 15 patients (14 male and 1 female) had 32 episodes of TPP which were analyzed. The mean age was 30.2±6.2 yr (range: 21-39), and overt thyrotoxicosis was seen in all patients except one who had subclinical hyperthyroidism. Graves' disease was the most common cause of thyrotoxicosis (13/15) and the remaining two patients had subacute thyroiditis and gestational thyrotoxicosis. Hypokalaemia (serum potassium <3.5 mmol/l) was seen in 12 patients, and the mean serum potassium was 3.2±0.9 mmol/l (range: 2.1-4.9). All patients had flaccid weakness, predominantly involving the lower limb with no bulbar, respiratory or cranial nerve involvement. The average duration of paralysis was 10.6±5.7 h (range: 3-28 h).
Interpretation & conclusions: Our study demonstrated an early age of presentation and presence of clinical and biochemical thyrotoxicosis in majority of patients with TPP. Hypokalaemia may not always be evident in patients with TPP.

Thyrotoxic periodic paralysis: A retrospective, observational study from India.

AIMS
Risk stratification is used for decisions regarding need for imaging in patients with clinically suspected acute pulmonary embolism (PE). The aim was to develop a clinical prediction model that provides an individualized, accurate probability estimate for the presence of acute PE in patients with suspected disease based on readily available clinical items and D-dimer concentrations.


METHODS AND RESULTS
An individual patient data meta-analysis was performed based on sixteen cross-sectional or prospective studies with data from 28 305 adult patients with clinically suspected PE from various clinical settings, including primary care, emergency care, hospitalized and nursing home patients. A multilevel logistic regression model was built and validated including ten a priori defined objective candidate predictors to predict objectively confirmed PE at baseline or venous thromboembolism (VTE) during follow-up of 30 to 90 days. Multiple imputation was used for missing data. Backward elimination was performed with a P-value <0.10. Discrimination (c-statistic with 95% confidence intervals [CI] and prediction intervals [PI]) and calibration (outcome:expected [O:E] ratio and calibration plot) were evaluated based on internal-external cross-validation. The accuracy of the model was subsequently compared with algorithms based on the Wells score and D-dimer testing. The final model included age (in years), sex, previous VTE, recent surgery or immobilization, haemoptysis, cancer, clinical signs of deep vein thrombosis, inpatient status, D-dimer (in µg/L), and an interaction term between age and D-dimer. The pooled c-statistic was 0.87 (95% CI, 0.85-0.89; 95% PI, 0.77-0.93) and overall calibration was very good (pooled O:E ratio, 0.99; 95% CI, 0.87-1.14; 95% PI, 0.55-1.79). The model slightly overestimated VTE probability in the lower range of estimated probabilities. Discrimination of the current model in the validation data sets was better than that of the Wells score combined with a D-dimer threshold based on age (c-statistic 0.73; 95% CI, 0.70-0.75) or structured clinical pretest probability (c-statistic 0.79; 95% CI, 0.76-0.81).


CONCLUSION
The present model provides an absolute, individualized probability of PE presence in a broad population of patients with suspected PE, with very good discrimination and calibration. Its clinical utility needs to be evaluated in a prospective management or impact study.


REGISTRATION
PROSPERO ID 89366.

Diagnostic management of acute pulmonary embolism: a prediction model based on a patient data meta-analysis.

BackgroundA positive D-dimer test has high sensitivity but relatively poor specificity for the diagnosis of pulmonary embolism, causing difficulty for clinicians unskilled in pulmonary embolism dia...

https://journals.sagepub.com/doi/pdf/10.1177/2045894020943378

Diagnostic management of inpatients with a positive D-dimer test: developing a new clinical decision-making rule for pulmonary embolism.

A variety of evidence-based algorithms and decision rules using D-Dimer testing have been proposed as instruments to allow physicians to safely rule out a pulmonary embolism (PE) in low-risk patients. To describe the prevalence of D-Dimer utilization among emergency department (ED) physicians and its impact on positive yields and utilization rates of Computed Tomography Pulmonary Angiography (CTPA). Data was collected on all CTPA studies ordered by ED physicians at three sites during a 2-year period. Using a chi-square test, we compared the diagnostic yield for those patients who had a D-Dimer prior to their CTPA and those who did not. Secondary analysis was done to examine the impact of D-Dimer testing prior to CTPA on individual physician diagnostic yield or utilization rate. A total of 2811 CTPAs were included in the analysis. Of these, 964 CTPAs (34.3%) were ordered without a D-Dimer, and 343 (18.7%) underwent a CTPA despite a negative D-Dimer. Those CTPAs preceded by a D-Dimer showed no significant difference in positive yields when compared to those ordered without a D-Dimer (9.9% versus 11.3%, p = 0.26). At the individual physician level, no statistically significant relationship was found between D-Dimer utilization and CTPA utilization rate or diagnostic yield. This study provides evidence of suboptimal adherence to guidelines in terms of D-Dimer screening prior to CTPA, and forgoing CTPAs in patients with negative D-Dimers. However, the lack of a positive impact of D-Dimer testing on either CTPA diagnostic yield or utilization rate is indicative of issues relating to the high false-positive rates associated with D-Dimer screening.

/pdf/utilization-of-serum-d-dimer-assays-prior-to-computed-2d8ae7kffq.pdf

Utilization of serum D-dimer assays prior to computed tomography pulmonary angiography scans in the diagnosis of pulmonary embolism among emergency department physicians: a retrospective observational study.

Background Assessment for pulmonary embolism (PE) in the emergency department (ED) remains complex, involving clinical decision tools, blood tests, and imaging. Objective Our objective was to examine the test characteristics of the high-sensitivity d -dimer for the diagnosis of PE at our institution and evaluate use of the d -dimer and factors associated with a falsely elevated d -dimer. Methods We retrospectively collected data on adult patients evaluated with a d -dimer and computed tomography (CT) pulmonary angiogram or ventilation perfusion scan at two EDs between June 4, 2012 and March 30, 2016. We collected symptoms (dyspnea, unilateral leg swelling, hemoptysis), vital signs, and medical and social history (cancer, recent surgery, medications, history of deep vein thrombosis or PE, chronic obstructive pulmonary disease, smoking). We calculated test characteristics, including sensitivity, specificity, and likelihood ratios for the assay using conventional threshold and with age adjustment, and performed a univariate analysis. Results We found 3523 unique visits with d -dimer and imaging, detecting 198 PE. Imaging was pursued on 1270 patients with negative d -dimers, revealing 9 false negatives, and d -dimer was sent on 596 patients for whom negative Pulmonary Embolism Rule-Out Criteria (PERC) were documented with 2% subsequent radiographic detection of PE. The d -dimer showed a sensitivity of 95.7% (95% confidence interval [CI] 91–98%), specificity of 40.0% (95% CI 38–42%), negative likelihood ratio of 0.11 (95% CI 0.06–0.21), and positive likelihood ratio of 1.59 (95% CI 1.53–1.66) for the radiographic detection of PE. With age adjustment, 347 of the 2253 CT scans that were pursued in patients older than 50 years with an elevated d -dimer could have been avoided without missing any additional PE. Many risk factors, such as age, history of PE, recent surgery, shortness of breath, tachycardia and hypoxia, elevated the d -dimer, regardless of the presence of PE. Conclusions Many patients with negative d -dimer and PERC still received imaging. Our data support the use of age adjustment, and perhaps adjustment for other factors seen in patients evaluated for PE.

Use of the d-dimer for Detecting Pulmonary Embolism in the Emergency Department.

Background Periodic paralysis is a rare complication of hyperthyroidism. Patients of East Asian descent are most commonly affected. Presentation is characterized by recurrent episodes of painless, abrupt-onset weakness, with laboratory evaluation characterized by profound hypokalemia. Underlying hyperthyroidism may not be clinically evident, but differentiation from the familial variant is critical due to differing treatment pathways. Case Report We describe the presentation of a 22-year-old man with recurrent relapsing-remitting weakness with undiagnosed hyperthyroidism. Why Should an Emergency Physician Be Aware of This? In patients with acute-onset paralysis with significant hypokalemia, or relapsing-remitting symptoms, hyperthyroidism should be suspected. Obese patients are at an especially increased risk due to underlying insulin resistance, which enhances basal sodium-potassium ATPase function. Hypokalemia is functional in nature. Nonselective β-blockers (such as propranolol) should be considered first line, as they simultaneously decrease ATPase activity, limit insulin secretion, and address the underlying disorder. Administration of > 50 mEq of exogenous potassium places patients at risk of dysrhythmias from rebound hyperkalemia.

Changing Management Guidelines in Thyrotoxic Hypokalemic Periodic Paralysis.

A spontaneous diaphragmatic hernia (SDH) occurs when intra-abdominal contents extend into the thoracic cavity through a defect in the diaphragm after a sudden increase in intra-abdominal pressure. SDH is one of the rarest surgical emergencies with less than 30 reported cases in the literature.1,2 In our case a 94-year-old female presented to the emergency department in respiratory distress with unilateral breath sounds and was diagnosed with a SDH. The only treatment option for a SDH is surgical.3,11 However, nasogastric tube decompression of the gastrointestinal tract and supplemental oxygen can be used to alleviate symptoms until definitive operative management is performed.

/pdf/spontaneous-diaphragmatic-hernia-59e8lo386w.pdf

Spontaneous Diaphragmatic Hernia

We generated a novel scoring system to improve the test characteristics of D-dimer in patients with suspected PE (pulmonary emboli). Electronic Medical Record data were retrospectively reviewed on Emergency Department (ED) patients 18 years or older for whom a D-dimer and imaging were ordered between June 4, 2012 and March 30, 2016. Symptoms (dyspnea, unilateral leg swelling, hemoptysis), age, vital signs, medical history (cancer, recent surgery, medications, history of deep vein thrombosis or PE, COPD, smoking), laboratory values (quantitative D-dimer, platelets, and mean platelet volume (MPV)), and imaging results (CT, VQ) were collected. Points were designated to factors that were significant in two multiple regression analyses, for PE or positive D-dimer. Points predictive of PE were designated positive values and points predictive of positive D-dimer, irrespective of presence of PE, were designated negative values. The DAGMAR (D-dimer Assay-Guided Moderation of Adjusted Risk) score was developed using age and platelet adjustment and points for factors associated with PE and elevated D-dimer. Of 8486 visits reviewed, 3523 were unique visits with imaging, yielding 2253 (26.5%) positive D-dimers. 3501 CT scans and 156 VQ scans were completed, detecting 198 PE. In our cohort, a DAGMAR Score  By considering factors that affect D-dimer and also PE, we improved specificity without compromising sensitivity.

The DAGMAR Score: D-dimer assay-guided moderation of adjusted risk. Improving specificity of the D-dimer for pulmonary embolism.

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Papers

Use of the d-dimer for Detecting Pulmonary Embolism in the Emergency Department.

Changing Management Guidelines in Thyrotoxic Hypokalemic Periodic Paralysis.

Spontaneous Diaphragmatic Hernia

The DAGMAR Score: D-dimer assay-guided moderation of adjusted risk. Improving specificity of the D-dimer for pulmonary embolism.