Performance of the 4-Level Pulmonary Embolism Clinical Probability Score (4PEPS) in the diagnostic management of pulmonary embolism:An external validation study

Background: The recently published 4-level Pulmonary Embolism Clinical Probability Score (4PEPS) integrates different aspects from currently available diagnostic strategies to further reduce imaging testing in patients with clinically suspected pulmonary embolism (PE). Aim: To externally validate the performance of 4PEPS in an independent cohort. Methods: In this post-hoc analysis of the prospective diagnostic management YEARS study, the primary outcome measures were discrimination, calibration, efficiency (proportion of imaging tests potentially avoided), and failure rate (venous thromboembolism (VTE) diagnosis at baseline or follow-up in patients with a negative 4PEPS algorithm). Multiple imputation was used for missing 4PEPS items. Based on 4PEPS, PE was considered ruled out in patients with a very low clinical pre-test probability (CPTP) without D-dimer testing, in patients with a low CPTP and D-dimer &lt;1000 μg/L, and in patients with a moderate CPP and D-dimer below the age-adjusted threshold. Results: Of the 3465 patients, 474 (14 %) were diagnosed with VTE at baseline or during 3-month follow-up. Discriminatory performance of the 4PEPS items was good (area under ROC-curve, 0.82; 95%CI, 0.80–0.84) as was calibration. Based on 4PEPS, PE could be considered ruled out without imaging in 58 % (95%CI 57–60) of patients (efficiency), for an overall failure rate of 1.3 % (95%CI 0.86–1.9). Conclusion: In this retrospective external validation, 4PEPS appeared to safely rule out PE with a high efficiency. Nevertheless, although not exceeding the failure rate margin by ISTH standards, the observed failure rate in our analysis appeared to be higher than in the original 4PEPS derivation and validation study. This highlights the importance of a prospective outcome study.</p

Hyponatriëmie: stel de juiste vragen.

Hyponatraemia is a common but complex electrolyte disorder. This clinical lesson, based on two case histories, illustrates how asking the right questions will not only lead to the correct diagnosis and treatment of hyponatraemia but can also indicate how the condition is endangering the patient

Hyponatriëmie: Stel de juiste vragen

Asking the right questions in these two cases helped to identify their dangers and to plan the right treatment. In both patients hyponatraemia was truly hypotonic (low serum osmolality). In the first patient, hyponatraemia was acute and symptomatic, warranting hypertonic saline for cerebral edema. In the second patient hyponatraemia was likely chronic, but she was mildly symptomatic. Therefore, a moderate rise in serum sodium was established with hypertonic saline, followed by a gradual correction to prevent osmotic demyelination. In both patients vasopressin was elevated (high urine osmolality) due to their medication (risperidone and the thiazide diuretic, respectively). Finally, both patients did not have signs of a low effective arterial blood volume and therefore had no indication for treatment with isotonic saline

[Hyponatraemia:ask the right questions].

Hyponatraemia is a common but complex electrolyte disorder. This clinical lesson, based on two case histories, illustrates how asking the right questions will not only lead to the correct diagnosis and treatment of hyponatraemia but can also indicate how the condition is endangering the patient.</p

Hyponatraemia:Ask the right questions

Asking the right questions in these two cases helped to identify their dangers and to plan the right treatment. In both patients hyponatraemia was truly hypotonic (low serum osmolality). In the first patient, hyponatraemia was acute and symptomatic, warranting hypertonic saline for cerebral edema. In the second patient hyponatraemia was likely chronic, but she was mildly symptomatic. Therefore, a moderate rise in serum sodium was established with hypertonic saline, followed by a gradual correction to prevent osmotic demyelination. In both patients vasopressin was elevated (high urine osmolality) due to their medication (risperidone and the thiazide diuretic, respectively). Finally, both patients did not have signs of a low effective arterial blood volume and therefore had no indication for treatment with isotonic saline.</p

Short-term versus extended anticoagulant treatment for unprovoked venous thromboembolism : A survey on guideline adherence and physicians' considerations

Background: In patients with unprovoked venous thromboembolism (VTE), anticoagulant treatment duration should be decided by weighing bleeding risk versus risk of recurrent VTE, considering patient's preference. Because both risks differ between individuals, this recommendation presumably leads to wide variation in clinical management. Objectives: To identify physician's considerations when deciding between short-term and extended anticoagulation and to assess how current guidelines are put to practice. Materials and methods: An online, 33-item survey was developed, containing questions on clinical management, considerations regarding treatment duration, risk scores, information tools and shared decision-making. It was distributed to internists, pulmonologists and residents treating patients with VTE in the Netherlands. Results: 69 internists and 73 pulmonologists including 24 residents participated in the survey. Extended treatment was preferred by 73% (104/142) of participants. Most important reasons for extended treatment were, in descending order: patient's preference, active malignancy, low estimated bleeding risk, history of VTE and hemodynamic instability during previous VTE. Most important reasons for short-term treatment were frequent falls, history of major bleeding, previous bleeding during anticoagulation, patient's preference and thrombocytopenia. Although existing risk scores are infrequently used, physicians express their need for scores combining risks of recurrence and bleeding to aid individualized decision-making. Conclusion: Our results confirm a wide variety of considerations regarding treatment duration in patients with unprovoked VTE. Although most participants followed guidelines' recommendations to prescribe indefinite treatment in absence of contraindications, rationale is not always supported by evidence. A clinical decision tool to estimate and weigh risks of recurrence and bleeding is warranted

Design, validation and implementation of an automated e-alert for acute kidney injury: 6-month pilot study shows increased awareness

Abstract Background Acute kidney injury (AKI) is defined as a sudden episode of kidney failure but is known to be under-recognized by healthcare professionals. The Kidney Disease Improving Global Outcome (KDIGO) guidelines have formulated criteria to facilitate AKI diagnosis by comparing changes in plasma creatinine measurements (PCr). To improve AKI awareness, we implemented these criteria as an electronic alert (e-alert), in our electronic health record (EHR) system. Methods For every new PCr measurement measured in the University Medical Center Utrecht that triggered the e-alert, we provided the physician with actionable insights in the form of a memo, to improve or stabilize kidney function. Since e-alerts qualify for software as a medical device (SaMD), we designed, implemented and validated the e-alert according to the European Union In Vitro Diagnostic Regulation (IVDR). Results We evaluated the impact of the e-alert using pilot data six months before and after implementation. 2,053 e-alerts of 866 patients were triggered in the before implementation, and 1,970 e-alerts of 853 patients were triggered after implementation. We found improvements in AKI awareness as measured by (1) 2 days PCr follow up (56.6–65.8%, p-value: 0.003), and (2) stop of nephrotoxic medication within 7 days of the e-alert (59.2–63.2%, p-value: 0.002). Conclusion Here, we describe the design and implementation of the e-alert in line with the IVDR, leveraging a multi-disciplinary team consisting of physicians, clinical chemists, data managers and data scientists, and share our firsts results that indicate an improved awareness among treating physicians