Death In Hospitalized Patients Research Articles

Application of the Caprini Risk Assessment Model in predicting the risk of venous thromboembolism

Venous thromboembolism (VTE) is one of the most important leading causes of death in hospitalized patients. It is often asymptomatic, leading to long-term complications and results in death. VTE prophylaxis can reduce the incidence rate of VTE and is an important component in the safety management of hospitalized patients. VTE risk assessment plays an important role in thrombosis prevention. Recently, the Caprini risk assessment model has been validated worldwide. In this study, the research progress of the Caprini risk assessment model were reviewed to provide reference for clinical application of the Caprini risk assessment model. Key words: Review; Venous thromboembolism; Caprini risk assessment model

A Quantile Analysis of Plateau and Driving Pressures: Effects on Mortality in Patients With Acute Respiratory Distress Syndrome Receiving Lung-Protective Ventilation.

The driving pressure (plateau pressure minus positive end-expiratory pressure) has been suggested as the major determinant for the beneficial effects of lung-protective ventilation. We tested whether driving pressure was superior to the variables that define it in predicting outcome in patients with acute respiratory distress syndrome. A secondary analysis of existing data from previously reported observational studies. A network of ICUs. We studied 778 patients with moderate to severe acute respiratory distress syndrome. None. We assessed the risk of hospital death based on quantiles of tidal volume, positive end-expiratory pressure, plateau pressure, and driving pressure evaluated at 24 hours after acute respiratory distress syndrome diagnosis while ventilated with standardized lung-protective ventilation. We derived our model using individual data from 478 acute respiratory distress syndrome patients and assessed its replicability in a separate cohort of 300 acute respiratory distress syndrome patients. Tidal volume and positive end-expiratory pressure had no impact on mortality. We identified a plateau pressure cut-off value of 29 cm H2O, above which an ordinal increment was accompanied by an increment of risk of death. We identified a driving pressure cut-off value of 19 cm H2O where an ordinal increment was accompanied by an increment of risk of death. When we cross tabulated patients with plateau pressure less than 30 and plateau pressure greater than or equal to 30 with those with driving pressure less than 19 and driving pressure greater than or equal to 19, plateau pressure provided a slightly better prediction of outcome than driving pressure in both the derivation and validation cohorts (p < 0.0000001). Plateau pressure was slightly better than driving pressure in predicting hospital death in patients managed with lung-protective ventilation evaluated on standardized ventilator settings 24 hours after acute respiratory distress syndrome onset.

Extracorporeal membrane oxygenation in transcatheter aortic valve replacement.

Background Patients undergoing transcatheter aortic valve replacement can experience severe perioperative complications leading to hemodynamic instability and death. Venoarterial extracorporeal membrane oxygenation can be used to provide cardiorespiratory support during this time. Methods From 2012 to 2015, of 247 patients who underwent transcatheter aortic valve replacement, 6 (2.42%) required extracorporeal membrane oxygenation support. Their mean age was 82 ± 7.4 years, mean Society of Thoracic Surgeons score was 9.4 ± 6.6, and mean aortic gradient was 28.3 ± 12 mm Hg. Rescue extracorporeal membrane oxygenation was required for hemodynamic instability due to ventricular fibrillation ( n = 1), respiratory failure ( n = 1), left ventricular wall rupture ( n = 2), and aortic annulus rupture ( n = 1). In one patient, prophylactic extracorporeal membrane oxygenation was required due to advanced heart failure. Additional procedures included valve-in-valve implantation ( n = 1), conversion to an open procedure ( n = 3), and intraaortic balloon pump insertion ( n = 1). Results The median hospital stay was 20 days. There were 2 hospital deaths in patients whose hospital course was complicated by left ventricular wall rupture or aortic annulus rupture with resulting tamponade. Among the 4 survivors, one required continuous ventilator support following discharge, and 3 experienced no major complications during the first month after discharge. Conclusions Extracorporeal membrane oxygenation can be considered a viable option for high-risk patients undergoing transcatheter aortic valve replacement and those who develop cardiac complications following this procedure and require cardiorespiratory support.

Ageing acute surgical population: the Auckland experience.

This study provides data supporting the supposition that more elderly patients are requiring surgical care and illustrates the risks associated with acute surgical illness in elderly patients. The clinical records database was accessed to identify all patients discharged from general surgery and acute surgical unit (ASU) during 2013 and 2014. These groups were stratified by age (over 80 years). Data were collected on number of patients discharged per year, length of stay, number of intensive care unit admissions and number of procedures and mortality rates. There is an increasing number of patients aged over 80 years who were discharged from ASU; 7.02% (n = 296) in 2013 and 8.20% (n = 344) in 2014. Patients aged over 80 years were spending 1.88 days (P-value < 0.001) longer in hospital than those under 80 years in 2014. Mortality rates in 2013 were 3.716 deaths per 100 admissions and 5.814 per 100 admissions in 2014. In 2013, the risk ratio of death in hospital for patients over 80 years was 36.4 (P-value < 0.001) times higher than patients under 80 years. The mean length of stay and mortality rates are higher for patients over 80 years. Mortality rates are higher in acute admissions compared with elective admissions. This identifies a need for increased care for elderly patients admitted for acute surgical care. We suggest a trial of attaching a specialist geriatrician to the ASU who will provide a service for at risk patients.

Topics in medicine 50 years ago

Topics in medicine 50 years ago

Characteristics and outcomes of advanced cancer patients admitted to an acute palliative care unit (PCU) with severe dyspnea receiving high flow oxygen (HFO).

247 Background: Dyspnea is very complex and distressing symptom in patients with advanced cancer. The therapeutic goal of its symptomatic management is to relieve the patient’s breathlessness sensation. Limited literature has addressed the characteristics and clinical outcomes of advanced cancer patients with severe dyspnea receiving HFO admitted to PCU. Methods: We reviewed the records of 101 advanced cancer patients with dyspnea receiving HFO and 110 matched PCU inpatients with dyspnea receiving regular O2 flow (NoHFO) between January 1 to December 31, 2012. Demographics, frequency and intensity of symptoms at PCU admission and follow-up, and outcomes were recorded. Results: Median age: 60 years, range (51, 69). 56% were Male. White(71%), Hispanic(13%), African American(10%), Asian (4%). Primary cancer: Lung (27%), Gastrointestinal (19%), Hematological (18%), Breast (13%), Gynecological (6%). Dyspnea was present in all cases and it was related mainly to: lung involvement by cancer (53%), pneumonia (40%), Congestive Heart Failure (6%), COPD (8%). ECOG: 4. No significant difference in age, ethnicity and type of cancer, ECOG, and possible cause of dyspnea among both groups. HFO and NoHFO were started the same day of admission. Median ESAS symptoms (Interquartile range: IQR) for HFO was Pain 4.5 (2, 7) vs. 5 (3, 7) for NoHFO, p = 0.1423; fatigue [7(5, 8) vs. 7 (5, 8), p = 0.450]; depression [3 (1, 5) vs. 3.5 (2, 5), p = 0.81]; anxiety 7 (4, 9) vs. 6 (3, 8), p = 0.01; dyspnea [7.5( 6, 9) vs. 5 (3, 8), p &lt; 0.0001]. Memorial Delirium Scale 5 (2, 15) vs. 7(2, 15), p = 0.77). Morphine Equivalent Daily Dose: 48 (36, 120) vs. 55 (30, 120), p = 0.72. The median difference among first and follow up ESAS was Pain 0 (-3, 1) vs. -1(-2, 1), p = 0.62; fatigue[(-2, 1) vs. 0 (-2, 0), p = 0.63]; depression [0 (-1, 1) vs. 0 (-1, 2), p = 0.93]; anxiety [0 (-2, 2) vs. 0 (-2, 2), p = 0.94; dyspnea [0( -1, 1) vs. -1 (-2, 1), p = 0.18]. Memorial Delirium Scale 0 (-1.5, 5.5) vs. 0 (-2, 3), p = 0.21).The median time (IQR) from HFO started to discharge was 10 days (6, 15) vs. 8.5 (5, 14) days for NoHFO, p = 0.07). The median time(IQR) from HFO started to Death was 10.5 (7, 19) vs. 13.5 (7, 26) days for NoHFO, p = 0.18. 77/101(76%) HFO patients vs. 56/110 (51%) NoHFO died at the hospital, p = 0.002. 24/101(23%) HFO patients were discharged alive weaned off HFO. The Odd ratio for hospital death in patients with HFO vs. NoHFO was 4.83 (95% CI: 1.72 – 13.59), p = 0.003. Conclusions: Severe dyspnea is significant at the end of life of advanced cancer patients. Patients with HFO require similar MEDD than NoHFO patients. Inpatient mortality is higher in patients with HFO. More research is needed.

Analysis of clinical treatment of 162 cases of acute coronary syndrome

Objective To analyze acute coronary syndrome patients with clinical characteristics and the status survey of the interventional treatment in the datong area. Methods 162 cases of hospitalized patients with unstable angina pectoris(UA) and non ST segment elevation myocardial infarction(NSTEMI) were selected through clinical records,with UA78 cases and NSTEMI 84 cases. Results Clinical features:(1)Two groups of high incidence were men,and incidence cases were 2 times than that in women.Peaks in males were 50-60 years old,and lasted 20 years in UA group;Peaks delayed 10 years of women thanthat of men in UA group,delayed 20 years in NSTEMI group.Over the 70-year-old,there were no gender,number differences in the two groups.Hypertension,hyperlipidemia,diabetes,number of cases were quite in two groups.(2)The history of coronary heart disease (CHD) were respectively:in UA group,patients with 1 year or less were 48(61.5%),30 cases(38.5%)> 1 year. NSTEMI group had 67 cases(79.8%)in 1 year or less,> 1 year with 7 cases(20.2%),(t= 2.915,-2.743,all P< 0.01).In the subgroups which the morbidity was 1 day or less,UA group had 5 cases(6.4%),NSTEMIgroup had 25 cases(29.8%)(t= 4.066,P< 0.01).(3)History of OMI respectively:UA group 18 cases(23.1%),the NSTEMI group 8 cases(9.5%)(t=-2.533,P<0.05),the difference between the two groups had statistical significance.Coronary lesions:(1)stents:During 78 cases of patients with UA,direct percutaneous coronary intervention(PCI) treatment were 71 cases(91.0%).During 84 NSTEMI patients,direct PCI were 63 cases(75.0%).(2)Single lesion:UA group of stents treatment were 18 cases(11.1%),the NSTEMI group were10 cases(6.2%),and had a statistically significant difference between the two groups(χ2= 26.309 P< 0.01).The third.The incidence of heart for death in hospitalized patients:In the 162 cases of patients,hospital death was 3 patients(1.9%),and had occurred in NSTEMI group(3.6%),there was statistically significant difference between the two groups(χ2= 2.838 P1-sided< 0.05). Conclusion In front of coronary heart disease incidence peak,the high-risk groups:hypertension,hyperlipidemia,diabetes,to carry on the curative effect of standard treatment for a long time,it is the key to avoid the risk of coronary heart disease(CHD).NSTEMI cardiac mortality,need hospital treatment.Not only secondary prevention of coronary artery disease focus groups of HP, hyperlipidemia, DM and also cannot ignore OMI crowd. because myocardial ischemia often,even NSTEMI.Correct myocardial ischemia is the key of the coronary heart disease treatment,if the drug is invalid,stents treatment should be taken into account. Key words: Acute coronary syndrome; Myocardial infarction; Myocardial ischemia

Carboxyhemoglobin and methemoglobin levels as prognostic markers in acute pulmonary embolism

ObjectivesCarboxyhemoglobin (COHb) and methemoglobin (MetHb) levels have been associated with a poor outcome in patients with various pathological conditions including cardiovascular diseases. Our aim was to retrospectively assess the prognostic value of arterial COHb and MetHb in patients with acute pulmonary embolism (PE). MethodsWe conducted a retrospective study of 156 patients admitted in a pulmonary clinic due to acute PE. Measured variables during emergency department evaluation that were retrospectively analyzed included the ratio of the partial pressure of oxygen in arterial blood to the fraction of oxygen in inspired gas, Acute Physiology and Chronic Health Evaluation II score, risk stratification indices, and arterial blood gases. The association between arterial COHb and MetHb levels and disease severity or mortality was evaluated using bivariate tests and logistic regression analysis. ResultsArterial COHb and MetHb levels correlated with Acute Physiology and Chronic Health Evaluation II and pulmonary severity index scores. Furthermore, arterial COHb and MetHb levels were associated with troponin T and N-terminal pro–B-type natriuretic peptide levels. In univariate logistic regression analysis, COHb and MetHb levels were both significantly associated with an increased risk of death. However, in multivariate analysis, only COHb remained significant as an independent predictor of in-hospital mortality. ConclusionOur preliminary data suggest that arterial COHb and MetHb levels reflect the severity of acute PE, whereas COHb levels are independent predictors of in hospital death in patients in this clinical setting. These findings require further prospective validation.

Risk Factors for Hospital Death in Patients With Acute Aortic Dissection

To determine the risk factors leading to hospital death with acute aortic dissection (AAD) patients and then to develop a simple risk prediction model to identify patients at increased risk of hospital death. A total of 360 patients with AAD were enrolled. Thirty risk factors were used in the statistical analysis for predicting hospital death. Risk factors for hospital death were investigated with univariate and multiple logistic regression analysis. The hospital mortality rate was 21.4% (77 of 360 patients). Univariate analysis revealed 12 risk factors to be statistically significant predictors of hospital death (P<0.05). Multiple logistic regression analysis identified that type A (OR, 10.53; P=0.001), hypotension (OR, 5.72; P=0.04), syncope (OR, 8.24; P=0.03), ischaemic complications (OR, 4.67; P=0.05), renal dysfunction (OR, 31.32; P<0.001), and neutrophil percentage ≥80% (OR, 5.67; P=0.01) were significant predictors of in-hospital death. With the simple prediction model, a total score of 4 offered the best point value. Independent risk factors for hospital death can be predicted with AAD patients. The risk prediction model could be used to identify the prognosis and to quickly determine the therapeutic technique for AAD patients.

Impact of the national venous thromboembolism risk assessment tool in secondary care in England

Venous thromboembolism (VTE) is a common and important cause of death in hospital patients. We therefore investigated possible associations between the introduction of the compulsory national VTE risk assessment tool in England in 2010 and patient outcomes. A retrospective database study, using data from the Health and Social Care Information Centre and Office of National Statistics, was undertaken. The main outcome measures were VTE-related secondary diagnosis rates, 30-day and 90-day readmission rates and mortality rates. The observed mean VTE-related secondary diagnosis rate for 2011–2012 was 91% of the rate estimated from a linear regression model of the data for 2006–2007 to 2010–2011 (P = 0.001). Similarly, the observed mean 30-day VTE-related readmission rate for 2011 was 96% of the estimated rate (P = 0.067) and the observed mean 90-day VTE-related readmission rate for 2011 was 96% of the estimated rate (P = 0.022). The observed annual VTE-related national mortality rate was 91% of the estimated rate for 2011 and 92% of the estimated rate for 2012. This study shows a reduction in VTE-related secondary diagnoses and readmissions among adults admitted to hospital, and a reduction in VTE-related population mortality, since the introduction of a national VTE risk assessment screening tool in England. Despite some study limitations, this suggests that the concerted effort made by NHS England to improve prevention of hospital-acquired VTE has been successful.

Hospital deaths in patients with sepsis from 2 independent cohorts.

Sepsis, the inflammatory response to infection, affects millions of patients worldwide.1 However, its effect on overall hospital mortality has not been measured. We quantified the contribution of sepsis to mortality in 2 complementary inpatient cohorts from Kaiser Permanente Northern California (KPNC) and the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (NIS).

The Impact of Rapid Response Team on Outcome of Patients Transferred From the Ward to the ICU

To determine the impact of rapid response team implementation on the outcome of patients transferred from the regular hospital ward and nonward locations to the ICU. Retrospective before-after cohort study. The study was performed in two ICUs, one surgical and one medical, of a tertiary medical center. We included 4,890 patients transferred from the hospital ward to two ICUs and 15,855 patients admitted from nonward locations. None. Data on each patient were abstracted from the Acute Physiology and Chronic Health Evaluation III and the administrative hospital and rapid response team databases. The study period was divided into pre-rapid response team and rapid response team. A 24/7 critical care consult service and cardiac arrest teams were available for ward patient care during both periods. A total of 20,745 patients were admitted to the two study ICUs, of whom 4,890 were from the ward (2,466 and 2,424 during the pre-rapid response team and rapid response team periods, respectively). The first ICU day severity of illness was higher for the pre-rapid response team period. A multiple logistic regression model that included predicted mortality as a covariate suggested that availability of rapid response team was associated with an increased risk of hospital death in patients transferred to the ICU from the regular ward, odds ratio (95% CI) of 1.273 (1.089-1.490). For the nonward patients, the availability of rapid response team was similarly associated with increased risk of death. The ICU length of stay was shorter during the rapid response team period both in ward transfer and in nonward transfer patients. Rapid response team implementation is associated with increased numbers of ICU admissions and rates, and transfer from the ward of less severely ill patients. However, rapid response team implementation did not improve the severity-of-illness-adjusted outcome of patients transferred from the ward. Implementation of rapid response team in an institution with a 24/7 ICU consult service may have unforeseen costs without obvious benefit. Our findings highlight that institutions should evaluate the impact of rapid response team on patient outcome and make modifications specific to their practices.

Predictive value of serum C-reactive protein for hospital death in patients with severe community-acquired pneumonia

Objective To evaluate the predictive value of serum C-reactive protein(CRP) for hospital death events in patients with severe community-acquired pneumonia(CAP).Methods The clinical data of 202 patients with CAP in Changhai Hospital and Second People's Hospital of Wuxi between Sep.2006 and Sep.2010 were retrospectively reviewed.The clinical and laboratory parameters,including the serum CRP level,white blood cell count,erythrocyte sedimentation rate(ESR) and serum creatine concentration were collected from Hospital Information System(HIS) and Laboratory Information System(LIS).The patients were divided into two groups according to the final death(CAP related complications) or survival of patients in the hospital.The receiver operating curve(ROC) analysis and multivariable logistical model were used to assess the predictive value of CRP on hospital death events.Results The median(interquartile range) serum CRP level of survival patients and patients who died during the hospital stay were 167.00(132.50,208.50) mg/L and 327.00(246.25,411.50) mg/L,respectively(Z=-7.481,P0.001).ROC analysis showed that CRP was an effective predictor for hospital death of CAP patients,with the area under curve(AUC) being 0.85(95%CI: 0.78-0.91).The optimal cot-off value for serum CRP was 230.50 mg/L,with the sensitivity being 0.83(95%CI: 0.76-0.89) and specificity being 0.79(95%CI: 0.65-0.89).Logistic regression analysis showed that,after adjusted for age,serum creatinine and ESR,CRP on admission was still independently associated with hospital death of CAP patients(OR=13.42,P0.01).Conclusion Increased CRP is an independent risk factor for hospital death events in patients with severe CAP.

Preoperative arterial blood lactate levels as a predictor of hospital mortality in patients with a ruptured abdominal aortic aneurysm

To establish if preoperative arterial blood lactate (Lac) is a factor related to hospital death for patients with a ruptured abdominal aortic aneurysm (rAAA). The subjects were 55 patients who underwent surgery for an rAAA in a single institution between July, 2000 and November, 2009. Patients were divided into a survivor group and a non-survivor group. We compared the preoperative Lac levels and other data between the groups. There were ten hospital deaths. On univariate analysis, preoperative Lac levels, shock vital, cardiopulmonary resuscitation, Hardman index ≥3, and Glasgow aneurysm score ≥84 were significantly higher and preoperative hemoglobin was significantly lower in the non-survivor group. The postoperative mortality rate tended to increase with preoperative Lac levels. The mortality rate of patients with a preoperative Lac level higher than 9 mmol/l was 86 %. Those factors that had significant association with hospital mortality on univariate analysis were consecutively analyzed using multivariate logistic regression analysis. The multivariate logistic regression analysis revealed that a preoperative Lac level >9 mmol/l was the only independent risk factor of hospital mortality. The preoperative Lac level of patients with a rAAA may be a predictor of their prognosis.

Risk factors for hospital death after surgery for type A aortic dissection

This study was undertaken to identify perioperative risk factors for hospital death in patients undergoing surgery for acute type A aortic dissection. Between 2000 and 2009, 101 consecutive patients underwent emergency surgery for acute type A aortic dissection. Four patients died before institution of cardiopulmonary bypass or completion of the procedure. In the remaining 97 (68 men; mean age, 63.4±16.7 years), proximal repair was performed using ascending aortic replacement with valve re-suspension in 52 (53.6%) and composite valve graft replacement in 44 (45.4%). Distal repair required hemi- or total arch replacement in 42 (43.3%) patients. Overall hospital mortality reached 25.8% (25/97 patients). Logistic regression analysis revealed that advanced age, location of an intimal tear in the arch or more distally, and preoperative coronary malperfusion were significant independent risk factors for hospital death. No procedure-related variables were significant risk factors. Current hospital mortality in patients undergoing emergency surgery for acute type A aortic dissection remains high, but seems to be mainly determined by preoperative variables. More aggressive proximal or distal repairs were not associated with increased mortality.

A New Simple Model for Prediction of Hospital Mortality in Patients with Intracerebral Hemorrhage

The current prognostic models for mortality and functional outcome after intracerebral hemorrhage (ICH) are not simple enough. To predict the outcome of ICH, a new simple model, ICH index (ICHI), was established and evaluated in this study. Medical records of all cases with ICH in our hospital from January 2008 to August 2009 were reviewed. Multiple linear regression analyses were used to assess the contributions of independent variables to hospital mortality after ICH. Age, serum glucose, white blood cell counts (WBC), and Glasgow Coma Scale (GCS) score were found to be greatly associated with mortality. A formula of ICH index [ICHI = age (years)/10 + glucose (mmol/L) + WBC (10(9) /L) - GCS score] was established. Furthermore, the receiver operating characteristic (ROC) analyses were performed to estimate the predictive value of the ICHI. The model showed an area under the ROC curve (AURC) of 0.923 (95% CI: 0.883-0.963, P < 0.001). The best cut-off value of ICHI for mortality was 18, which gave sensitivity, specificity, and Youden's index of 0.65, 0.95, and 0.60, respectively. The hospital mortality was extremely increased when 18 < ICHI < 28 (mortality 72.0%) and when ICHI ≥ 28 (mortality 100%), in contrast with overall mortality (21.6%). The ICHI can be a simple predictive model and complementary to other prognostic models.

Impact of ureido/carboxypenicillin resistance on the prognosis of ventilator-associated pneumonia due to Pseudomonas aeruginosa

IntroductionAlthough Pseudomonas aeruginosa is a leading pathogen responsible for ventilator-associated pneumonia (VAP), the excess in mortality associated with multi-resistance in patients with P. aeruginosa VAP (PA-VAP), taking into account confounders such as treatment adequacy and prior length of stay in the ICU, has not yet been adequately estimated.MethodsA total of 223 episodes of PA-VAP recorded into the Outcomerea database were evaluated. Patients with ureido/carboxy-resistant P. aeruginosa (PRPA) were compared with those with ureido/carboxy-sensitive P. aeruginosa (PSPA) after matching on duration of ICU stay at VAP onset and adjustment for confounders.ResultsFactors associated with onset of PRPA-VAP were as follows: admission to the ICU with septic shock, broad-spectrum antimicrobials at admission, prior use of ureido/carboxypenicillin, and colonization with PRPA before infection. Adequate antimicrobial therapy was more often delayed in the PRPA group. The crude ICU mortality rate and the hospital mortality rate were not different between the PRPA and the PSPA groups. In multivariate analysis, after controlling for time in the ICU before VAP diagnosis, neither ICU death (odds ratio (OR) = 0.73; 95% confidence interval (CI): 0.32 to 1.69; P = 0.46) nor hospital death (OR = 0.87; 95% CI: 0.38 to 1.99; P = 0.74) were increased in the presence of PRPA infection. This result remained unchanged in the subgroup of 87 patients who received adequate antimicrobial treatment on the day of VAP diagnosis.ConclusionsAfter adjustment, and despite the more frequent delay in the initiation of an adequate antimicrobial therapy in these patients, resistance to ureido/carboxypenicillin was not associated with ICU or hospital death in patients with PA-VAP.

Hypoglycemia in critically ill adults - association yes, causation not proven

Hypoglycemia is consistently associated with an increased risk of death in hospital patients in general, patients treated in intensive care units, and type II diabetes patients recruited to large randomized controlled trials. In 1965, Sir Austin Bradford Hill elucidated nine characteristics that help establish a causal relationship between exposure to a potentially harmful substance or event (in this context, hypoglycemia) and disease onset or death; hypoglycemia exhibits some of those characteristics but others remain to be explored. While we await data that address the outstanding issues, common sense dictates that clinicians avoid causing hypoglycemia whenever possible.

Graduated compression stockings to prevent venous thromboembolism in hospital. Evidence from patients with acute stroke

Pulmonary embolism is the most common preventable cause of death in hospital patients and prevention of venous thromboembolism (VTE) is cost-saving in high-risk patients. Low-dose anticoagulation is very effective at preventing VTE but increases bleeding. Graduated compression stockings and intermittent pneumatic compression devices are also used to prevent VTE and do not increase bleeding, which makes their use appealing in patients who cannot tolerate bleeding, such as patients with acute stroke. Studies that evaluated mechanical methods of preventing VTE were small and mainly used asymptomatic deep vein thrombosis (DVT), detected using screening tests, as the study outcome. The recently published CLOTS Trial 1 (Clots in Legs Or sTockings after Stroke) compared thigh-level compression stockings with no stockings in about 2500 patients with stroke and immobility, and found that thigh-level stockings were not effective. Indirectly, the findings of this study question the ability of stockings to prevent VTE in other patient groups, including those after surgery. CLOTS 1 compared thigh-level and below-knee stockings in about 3000 patients with acute stroke. Given that thigh-level stockings were ineffective in CLOTS 1, it is surprising that they were more effective than below-knee stockings in CLOTS Trial 2. A possible explanation is that below-knee stockings increase DVT, although this seems unlikely. CLOTS 1 and CLOTS 2 question whether graduated compression stockings prevent VTE and suggest the need for further trials evaluating their efficacy in medical and surgical patients.

Evaluation of an immunoturbidimetric D-dimer assay and pretest probability score for suspected venous thromboembolism in a district hospital setting

Venous thromboembolism is a leading cause of co-morbidity and death in hospital patients. This observational study looks at the usefulness of pretest probability and immunoturbidimetric D-dimer levels for the diagnosis of thromboembolic episodes in outpatients (108 of 197; 54·8%) and inpatients (89 of 197; 45·2%). Across 197 consecutive patients, D-dimers showed 100% sensitivity (95% CI, 87–100%). As a result, the combination of normal D-dimers and low or intermediate probability score yielded a negative predictive value of 100% (95% CI, 90·6–100%). The tests lacked specificity and positive predictive value. Normal D-dimer level in patients with low or intermediate pretest probability makes venous thromboembolism an unlikely diagnosis and may obviate the need for confirmatory scans. All other patients will need diagnostic imaging. Clinicians should be aware of the above utility and limitations while making management decisions for patients with suspected thromboembolism.