Background: The identification of patients who should undergo diagnostic testing for pulmonary embolism (PE) rests on the identification of clinical signs and symptoms. Because these findings are frequently subtle, diagnosis of PE is often delayed or missed.
Study design: Prospective multicenter study.
Setting: Eight academic centers, using a study focusing on inpatients and outpatients.
Synopsis: The most common clinical symptoms associated with PE were the hemoptysis/pleuritic chest pain syndrome (44%) and uncomplicated dyspnea (36%). Circulatory collapse was uncommon (8%). The most common presenting signs were tachypnea (57%), orthopnea (36%), tachycardia (26%), decreased breath sounds (21%), and crackles (21%). Neither oxygen saturation nor the A-a gradient provides useful diagnostic value in excluding PE.
Compared with segmental pulmonary artery embolism, proximal pulmonary emboli more often presented with typical signs and symptoms. Dyspnea, tachypnea, or pleuritic chest pain occurred in 77% of patients with segmental artery embolism.
Bottom Line: Because symptoms may be mild or even absent, a high level of clinical suspicion is critical for identifying patients in whom further diagnostic testing for pulmonary embolism is warranted.
Citation: Stein PD, Afzal B, Fadi M, et al. Clinical characteristics of patients with acute pulmonary embolism: Data from PIOPED II. Am J Med. 2007;120:871-879.
Background: The incidence of upper-extremity deep-vein thrombosis (DVT) is increasing although the risk factors and clinical outcomes are not as well established as for lower-extremity DVT.
Study design: Retrospective observational study.
Setting: Twelve hospitals serving the community of Worchester, Mass.
Synopsis: In this study of 483 people with DVT, the incidence of lower-extremity DVT was six times as common as upper-extremity DVT. The risk factor most strongly associated with upper-extremity DVT was a history of a recent indwelling central venous catheter. In this study, patients with upper-extremity DVT (69) were less likely to receive long-term anticoagulation with warfarin (Coumadin) than patients with lower-extremity DVT, although there were no differences in observed outcomes.
Recurrent upper-extremity DVT occurred in 10 of the 69 patients. Only one patient (1.5%) with an upper-extremity DVT suffered a PE, compared with 15% of patients with lower-extremity DVT.
There was not a significant incidence of PE associated with upper-extremity DVT in this study because of the low number of cases of upper-extremity DVTs (n=69). But hospitalists should not use the data to infer that upper-extremity DVT is a benign condition not requiring aggressive treatment.
Bottom Line: Upper-extremity DVT is strongly associated with central venous catheters. Further study is needed to define its appropriate treatment, possible prophylaxis, and associated morbidity.
Citation: Spencer FA, Emery C, Lessard D, et al. Upper extremity deep vein thrombosis: a community-based perspective. Am J Med. 2007;120:678-684.
Background: C. difficile-associated disease (CDAD) is an important hospital-acquired infection among critically ill patients. Risk factors for hospital mortality in critically ill patients with CDAD have not previously been identified.
Study design: A retrospective, single-center, observational, cohort study.
Setting: A 1,200-bed urban teaching facility.
Synopsis: During a two-year period, all patients in the ICU setting with a diagnosis of CDAD were evaluated. CDAD was defined by the presence of diarrhea or pseudomembranous colitis and a positive assay finding for C. difficile toxin A, toxin B, or both.
A crude 30-day mortality rate of 36.7% was found for patients with CDAD in the ICU setting. Significant risk factors for 30-day mortality included greater severity of illness, the presence of septic shock, and having CDAD develop on the hospital ward prior to ICU transfer. Mortality attributable to CDAD was relatively low (6.1%). CDAD was associated with an excess LOS in the ICU (2.2 days) and hospital LOS (4.5 days).