Indications For Hospital Admission Research Articles

Use of Neutrophil-to-Lymphocyte Ratio to Predict In-Hospital Mortality in Patients Admitted with Acute Decompensation of Atrial Fibrillation.

Background/Objectives: The prevalence of atrial fibrillation (AF) has been on the rise over the last 20 years. It is considered to be the most common cardiac arrhythmia and is associated with significant morbidity and mortality. The need for in-hospital management of patients having AF is increasing. Acute decompensation of cardiac rhythm is an indication for hospital admission. In the existing literature, several studies on different pathologies have observed that the risk of death was greater for patients with an increased neutrophil-to-lymphocyte ratio (NLR) and suggested that the NLR can be a useful biomarker to predict in-hospital mortality. This study aims to evaluate the link between the neutrophil-to-lymphocyte ratio at admission and death among the patients admitted to the medical ward for the acute manifestation of AF, and to gain a better understanding of how we can predict in-hospital all-cause death based on the NLR for these patients. Methods: A single-center retrospective study in an academic medical clinic was conducted. We analyzed if the NLR at in-hospital admission can be related to in-hospital mortality among the patients admitted for AF at the Medical Ward of Municipal Emergency University Hospital Timisoara between 2015 and 2016. After identifying a total of 1111 patients, we divided them into two groups: in-hospital death patients and surviving patients. We analyzed the NLR in both groups to determine if it is related to in-hospital mortality or not. One patient was excluded because of missing data. Results: Our analysis showed that patients who died during in-hospital admission had a significantly higher NLR compared to those who survived (p < 0.0001, 95% CI (1.54 to 3.48)). The NLR was found to be an independent predictor of in-hospital death among patients with AF, even for the patients with no raised level of blood leukocytes (p < 0.0001, 95% CI (0.6174 to 3.0440)). Additionally, there was a significant correlation between the NLR and the risk of in-hospital death for patients admitted with decompensated AF (p < 0.0001), with an area under the ROC curve of 0.745. Other factors can increase the risk of death for these patients (such as the personal history of stroke, HAS-BLED score, and age). Conclusions: The NLR is a useful biomarker to predict in-hospital mortality in patients with AF and can predict the risk of death with a sensitivity of 72.8% and a specificity of 70.4%. Further studies are needed to determine the clinical utility of the NLR in risk stratification and management of patients with AF.

Evaluating the consequences of critically ill patients with pediatric cancer at Aliasghar Children's Hospital.

Despite significant progress in supportive care and advancements in chemotherapy treatments, cancer remains a leading cause of mortality in children. The objective of this study was to assess the potential correlation between various risk factors and the consequences of patients with pediatric cancer who were admitted to the pediatric intensive care unit (PICU). The present investigation is a retrospective cohort study that examined children with cancer who were between the ages of 1 month and 17 years and had been admitted to the PICU. Demographic and clinical information of all patients, including such as the age, type of cancer, sex, BMI, history of specific disease, PICU admission time, disease condition on PICU admission, patient's status at PICU admission, and number of organ failures, were extracted from each patient file. The number of pediatric oncology patients admitted to the PICU was 127. The highest mortality rate was observed among children with heart problems (75%), followed by CNS involvement (54.2%) and sepsis (42.9%). The study found that various factors had a significant effect on the outcomes of patients who were admitted to the PICU, including but not limited to the primary type of malignancy, disease status, indications for hospital admission, patient's condition, inpatients' length of stay (LOS), tumor type, and the extent of organ failure at the time of admission to the PICU. Despite recent advancements in healthcare, the prognosis of patients admitted to the PICU in underdeveloped areas remains suboptimal in comparison to those in developed regions. Poor outcomes were found to be significantly associated with various factors, including the primary type of malignancy, disease status, the reason for admission to the PICU, patient's condition, LOS, tumor type, and the extent of organ failure, especially in cases involving hematological malignancies.

Bringing the hospital to home: Patient-reported outcome measures of a digital health-supported home hospitalisation platform to support hospital care at home for heart failure patients.

Hospitalisations for heart failure are frequent and costly, linked with a lower quality of life, and lead to higher morbidity and mortality. Home hospitalisation interventions could be a substitute for in-hospital stays to reduce the burden on patients. The current study aims to investigate patient-reported satisfaction and usability in combination with the safety of a digital health-supported home hospitalisation intervention for heart failure patients. We conducted an international, multicentre, single-arm, interventional study to investigate the feasibility and safety of a digital health-supported home hospitalisation platform. Patients with acute decompensation of known and well-assessed chronic heart failure with an indication for hospital admission were included. The primary outcome was patient satisfaction. Secondary outcomes were usability, adherence, and safety. A total number of 66 patients were included, of which the data of 65 patients (98.5%) was analysed. A total of 86.1% of patients reported being very satisfied or totally satisfied. No patients reported to be not satisfied with the home hospitalisation intervention. The patients reported a sufficient usability score (mean score: 75.8% of 100%) for the digital health-supported home hospitalisation platform. The adherence to the daily measurements of blood pressure and weight was very high, whereas the adherence to the daily interaction with the eCoach was lower (69.3%). In 7 patients (10.8%), a conversion from home hospitalisation to regular hospitalisation was needed. Furthermore, 6 patients (9.2%) had rehospitalisation within 30 days after the end of the home hospitalisation intervention. A digitally supported home hospitalisation intervention is feasible. This study demonstrates high patient satisfaction and sufficiently high usability scores. The safety outcomes are comparable with traditional heart failure hospitalisations. This indicates that digitally supported home hospitalisation could be an alternative to in-hospital care for all age groups, yet further research is needed to prove the (cost-) effectiveness.

Obstacles to Optimal Antenatal Corticosteroid Administration to Eligible Patients.

Administration of antenatal corticosteroids (ANCS) is recommended for individuals expected to deliver between 24 and 34 weeks of gestation. Properly timed administration of ANCS achieves maximal benefit. However, more than 50% of individuals receive ANCS outside the recommended window. This study aimed to examine maternal and hospital factors associated with suboptimal receipt of ANCS among individuals who deliver between 24 and 34 weeks of gestation. Secondary analysis of the Assessment of Perinatal Excellence (APEX), an observational study of births to 115,502 individuals at 25 hospitals in the United States from March 2008 to February 2011, was conducted. Data from 3,123 individuals who gave birth to a nonanomalous live-born infant between 240/7 to 340/7 weeks of gestation, had prenatal records available at delivery, and data available on the timing of ANCS use were included in this analysis. Eligible individuals' ANCS status was categorized as optimal (full course completed >24 hours after ANCS but not >7 days before birth) or suboptimal (none, too late, or too early). Maternal and hospital-level variables were compared using optimal as the referent group. Hierarchical multinomial logistic regression models, with site as a random effect, were used to identify maternal and hospital-level characteristics associated with optimal ANCS use. Overall, 83.6% (2,612/3,123) of eligible individuals received any treatment: 1,216 (38.9%) optimal and 1,907 (61.1%) suboptimal. Within suboptimal group, 495 (15.9%) received ANCS too late, 901 (28.9%) too early, and 511 (16.4%) did not receive any ANCS. Optimal ANCS varied depending on indication for hospital admission (p < 0.001). Individuals who were admitted with intent to deliver were less likely to receive optimal ANCS while individuals admitted for hypertensive diseases of pregnancy were most likely to receive optimal ANCS (10 vs. 35%). The median gestational age of individuals who received optimal ANCS was 31.0 weeks. Adjusting for hospital factors, hospitals with electronic medical records and who receive transfers have fewer eligible individuals who did not receive ANCS. ANCS administration and timing varied substantially by hospital, optimal frequencies ranged from 9.1 to 51.3%, and none frequencies from 6.1 to 61.8%. When evaluating variation by hospital site, models with maternal and hospital factors did not explain any of the variation in ANCS use. Optimal ANCS use varied by maternal and hospital factors and by hospital site, indicating opportunities for improvement. · Majority of individuals who deliver between 24 and 34 weeks of gestation do not receive properly timed antenatal corticosteroids.. · Optimal use of antenatal corticosteroids varies by maternal and hospital factors and hospital site.. · Significant variation in hospital sites regarding optimally timed administration of antenatal corticosteroids indicates opportunities for improvement..

Indications for hospital admission, prevalence of vascular and non-vascular complications and comorbidities among patients with diabetes mellitus admitted to a medical unit in a tertiary care hospital, Sri Lanka

The Asian Journal of Internal Medicine is the official journal of the Sri Lanka College of Internal Medicine. It is an open access peer-reviewed journal which is currently published bi-annually. AJIM’s mission is to achieve the supreme standards of holistic patient care by dissemination of high quality scientific knowledge related to Internal Medicine in the whole of Asia and Sri Lanka.

Agreements and controversies of national guidelines for bronchiolitis: Results from an Italian survey.

IntroductionSignificant variations in the management of bronchiolitis are often recorded, and, in parallel, to recommend a univocal clinical approach is challenging and still questioned. This study is aimed to evaluate the diagnostic and therapeutic management of bronchiolitis in children adopted by Italian pediatricians following the national guidelines.Material and MethodsA survey study was designed and carried out by sending an email an open‐ended questionnaire developed by an expert panel of the Scientific Board of the Italian Society of Pediatric Allergology and Immunology (SIAIP). Questions were designed according to the national intersociety consensus document on treatment and prevention of bronchiolitis in newborns and infants.ResultsOverall, 234 pediatricians were taking part in the study. When diagnosing bronchiolitis, only 44.01% (103/234) of participants correctly followed the national guidelines. All participants (100%) would perform laboratory tests and/or radiological exams. 44.01% administered oxygen (O2) when O2 saturation was minor than 92%. About the therapeutic regimen, marked discrepancies between national guidelines and recorded answers were reported. Indications for hospital admission and discharge criteria were in line with the national guidelines.ConclusionsThere is a significant practice variation in the management of acute bronchiolitis among Italian physicians. Some wrong attitudes need to be further discouraged, such use of diagnostic procedures and therapeutic approaches. Further research is urgently required to define the best management of patients with bronchiolitis and implement strategies to standardize care and improve the quality of care.

Gastroparesis in the Hospital Setting.

Gastroparesis (GP) is commonly seen in hospitalized patients. Refractory vomiting and related dehydration, electrolyte abnormalities, and malnutrition are indications for hospital admission. In addition, tube feeding intolerance is a common sign of gastric dysmotility in critically ill patients. The diagnosis and management of GP in the hospital setting can be quite challenging. Diagnostic tests are often deferred because of patient intolerance of the oral meal for standard scintigraphy or severity of the primary disease. The diagnosis of GP is often established on the basis of clinical scenario and risk factors for gastric motor dysfunction. Medical therapy in GP is directed toward controlling nausea and vomiting by prokinetic and antinausea medications and correcting nutrition risks or treating malnutrition with nutrition therapy. Enteral nutrition is the preferred nutrition intervention for patients with GP. Delayed gastric emptying in critically ill patients has a negative impact on the timely delivery of enteral feeding and meeting the energy and protein goals. Measures to improve gastric tolerance or provide feeding beyond the stomach are often needed, since early enteral nutrition has been an important target of therapy for critically ill patients. This review will address the current understanding of the mechanisms of GP and feeding intolerance in critical illness, diagnostic workup, drug therapies, and interventions to improve the provision of enteral nutrition in hospital settings when gastric dysmotility is present or suspected.

COVID-19 is not influenza

COVID-19 is not influenza

How COVID-19 has affected emergent visits to a Latin-American trauma department: Experience at a Peruvian national trauma referral center

IntroductionBy May 2020, Peru was the country with the third most COVID-19 cases in the Americas. The current study's overall aim was to examine the impact of the current COVID-19 outbreak on the number of non-COVID-related patient presentations to a major national emergency traumatology/orthopedics referral center in Latin America. MethodsAn observational study was performed at one of Peru's main tertiary trauma referral centers, during the current COVID-19 pandemic. Numbers of non-follow-up patients presenting to the traumatology/ orthopedics service were counted and compared between January through April 2019 and January through April 2020; and between the month immediately prior to the Peruvian government's implementation of national lock-down measures (Feb 16—Mar 15; Period 1) and the month immediately following (Mar 16—Apr 15; Period 2). The number of surgery service hospitalizations also was compared pre- versus post lockdown initiation (Period 1 vs. 2), as were patient characteristics and outcomes, like age, sex, discharge disposition, mortality, indications for hospital admission, and COVID-19 status. ResultComparing 2019 and 2020, no appreciable differences were detected in the number of patients seen in either January or February. However, relative to March and April 2019, the numbers of patients seen in March and April 2020 (the two months after the first Peruvian case of COVID-19 was detected) were reduced by 55.8 and 88.6%, respectively. Comparing the months immediately pre and post lockdown, the number of service patients declined by 79.9% in April, while the number of hospitalizations declined by 30.9%. The number of admissions for various surgical indications either remained stable or declined in parallel with the overall decline in admissions for all indications except for osteoporotic hip fractures and diabetic foot ulcers (both of which increased proportional to the overall number of admissions) and for hand and foot fractures, both of which decreased. ConclusionAt our hospital, not all indications for traumatology/orthopedics service utilization declined despite the national government's directive to reduce non-COVID-related consultations and admissions. Some disorders presented with even greater frequency, which must be considered when developing contingencies for the reallocation of healthcare resources during a pandemic.

Profile of Children Presenting with Epilepsy at a Tertiary Care Centre: A Hospital Based Cross Sectional Study

Background: Epilepsy is associated with significant mortality and morbidity. It is one of the common causes of childhood hospitalization. Regarding acute seizures episodes, there is limited data form the developing countries. This study aims to study the profile of children presenting with epilepsy at a Tertiary Care Centre. Subjects &amp; Methods: This was a hospital based, prospective cross-sectional study conducted at the ‘epilepsy clinic’ of Paediatric department of a Tertiary Care Center. Total 260 children with epilepsy and having the age of 1 months to 12 years attending to the epilepsy clinic during the study period, were studied for clinical features, types, imaging studies, EEG, etc. Results: Most of the children (59.61%) affected with epilepsy were males. Majority of the cases (108) were in the age group 1 month to 1 year age. It was observed that, 185 cases (71.15%) were born through pre term delivery. It was found that 214 cases (82.31%) had abnormal EEG, 40 cases had abnormal CT scan and 46 cases had abnormal MRI. A significant number of children (60.38%) had generalized tonic clonic seizures. Conclusion: Epilepsy in children is a common indication for hospital admission. Evaluation of the type of seizure type with specific EEG findings and other related investigations helps in early and appropriate initiation of treatment. It is utmost important that the children with seizures should be on regular long term follow up and treatment, for better prognosis and disease outcome.

Spectrum of seizure disorder in children between 1-18 years age at a tertiary care hospital: a longitudinal study

Background: To study the spectrum of seizures and types of anti-epileptic drugs in various types of seizures in children. Methods: A hospital based longitudinal study was conducted in the department of Pediatrics over two-years of period. A total of 161 cases presenting with seizures were studied for clinical features, imaging studies, EEG and pharmacotherapy given for various types of seizures (Monotherapy / combination therapy). Results: In the present study, the patient’s age ranged from 1year to 18 years. There were 72 (44.7%) females and 89 (55.2%) males. The male to female ratio was 0.8. Investigation like EEG, neuroimaging which included MRI / CT SCAN BRAIN were done. Out of 161 cases, EEG was done in all the cases, 89.44% (144) had EEG abnormality. 11% (17) presented with no EEG abnormality and MRI was done in 80.21% (129), out of which 53.48 % (68) were abnormal, CT scan was done in 19.87 % (32) of which 21.87% (7) were abnormal. Maximum used pharmacotherapeutic agent was sodium valproate (46.3 %) for generalised tonic clonic (GTCS) and minimum was combination of 3 anti-epileptic drugs (7%). Conclusion: Seizures in children are a common indication for hospital admission. They can be provoked or unprovoked. Early detection of the cause of seizures helps in instituting appropriate treatment. Children with seizures should be on regular long term follow up and treatment and proper response to therapy should be evaluated. Evaluation of the type of seizure with specific EEG findings helps in early and appropriate initiation of AED.

Caregiver Interventions for Adults Discharged from the Hospital: Systematic Review and Meta-Analysis.

To review the evidence evaluating the effectiveness of informal caregiver interventions to facilitate the recovery of older people discharged from the hospital. Systematic review and meta-analysis. Hospital and community. Published and unpublished randomized and nonrandomized controlled trials assessing the effectiveness of informal caregiver interventions to support the recovery of older people discharged from the hospital were identified (to March 2019). The primary outcome was patient health-related quality of life (HRQOL). Secondary outcomes included patient function, caregiver burden, caregiver HRQOL, psychological distress, adverse events, and health resource use. Studies were critically appraised and meta-analyzed. Adults who had been admitted to the hospital. A total of 23 studies were eligible (4695 participants). The indication for hospital admission was stroke in 21 trials (91%). Interventions consisted of training and/or skills-based programs, with or without home visits/telephone follow-up. Caregiver interventions for patients following stroke may provide no benefit for patient HRQOL at 12 months (standardized mean difference = .29; 95% confidence interval = -.12 to .69; low-quality evidence). Caregiver interventions demonstrated benefit for caregiver burden and both patient and caregiver anxiety at 12 months. No consistent effect was found on functional outcomes, depression, HRQOL, adverse events, or health resource use measures. Informal caregivers who receive training to facilitate the recovery of older people discharged from the hospital following stroke may have a lower burden and reduced anxiety at 12 months compared with those who do not. However, the evidence was moderate to low quality. Further study is warranted to explore whether caregiver interventions can be modified for nonstroke populations such as those with hip fracture. J Am Geriatr Soc 67:1960-1969, 2019.

Clinical features and outcome of sickle cell anemia in a tertiary center: A retrospective cohort study

Introduction: Sickle cell anemia (SCA) is one of the most common genetic diseases worldwide. Patients with SCA present with varied clinical features and complications that may affect many organs in the human body. There are few treatment options for SCA, and patient responses vary; the only curative therapy is a stem cell transplant or gene therapy. We seek to study the clinical features and treatment options for patients with sickle cell disease treated in King Abdulaziz Medical City, Riyadh. Methods: This study was a retrospective cohort study of all adult SCA patients who were admitted to our institution during the period from 1983 to 2016. Data were entered into Excel spreadsheets and managed with SPSS. Chi-square test was used to compare responses to therapy and in patients with different presentations. Results: A total of 106 patients with sickle cell disease were included in this study. The percentages with respect to hospital admissions per year were as follows: 34.9% (37 patients) were never admitted, 26.4% (28 patients) were admitted fewer than 2 times, 24.5% (26 patients) were admitted 3–5 times, and 13.2% (14 patients) were admitted more than 5 times. The number of complications was used to measure the severity of the disease. The disease severity was higher in males than in females (67.3% vs. 32.7%, respectively; P = 0.018). The disease severity was higher in those who were born in the Western and Southwestern areas than in other areas (84.2% vs. 15.8%, respectively; P = 0.007). Hydroxyurea significantly reduced the severity of SCA with a P = 0.002. Conclusion: Our study showed that vaso-occlusive crisis was the most common complication and indication for hospital admission. Treatment with hydroxyurea led to a significant reduction in the number of hospital admissions.

Restrictive versus Liberal Blood Transfusion Strategies in Egyptian Patients with Esophageal Variceal Bleeding

Background and Study Aim: Esophageal variceal bleeding is a major medical emergency and one of the most important indications for hospital admission and for blood transfusion. However, the safest and the effective blood transfusion strategy is controversial. Here, we studied the safety and the effectiveness of the restrictive versus liberal transfusion strategies in patients with esophageal variceal bleeding. Patients and Methods: The study included 342 patients with esophageal variceal bleeding. Patients were divided into 2 groups: group I (Restrictive strategy) transfusion when the hemoglobin level is ≤7 g/dl and group II (Liberal strategy): transfusion when the hemoglobin level is ≤9 g/dl. All patients were subjected to complete blood counts, liver and kidney profiles, coagulation profile, pelvi-abdominal ultrasonography and upper GI endoscopy. Clinical outcome measures include rebleeding, infection, allergic transfusion reactions thromboembolic events, and mortality. Results: Of all patients admitted to hospital with esophageal variceal bleeding, the number of transfused RBCs units and hospital stay were more in the liberal transfusion strategy. Also, the overall rate of complications was higher in the liberal transfusion strategy (49.7% versus 38.5% in the restrictive transfusion strategy). The most common complications were rebleeding (26.9%) and infection (21.6%). As regard the death rate, 13 cases (7.6%) died in the restrictive transfusion strategy versus 25 cases (14.6%) in the liberal transfusion one. Conclusions: For esophageal variceal bleeding, restrictive transfusion strategy is better than the liberal one as regard cost-effectiveness, risk of complications and hospital stay with no harm and less mortality as compared to liberal strategy.

Measles (lecture, continuing).

The second part of the article discusses differential diagnosis during different measles periods. Routine and confirmatory laboratory diagnosis, including cytological, serological and molecular genetic methods is outlined. Criteria of suspected, probable and proved diagnosis of measles cases are provided. Principles of diagnosis formulation according to WHO criteria are described. Complications of measles ac­cording to cause (viral and bacterial), by different systems and particularities in high risk patients are considered. Complications of measles from central nervous system are described in details. Therapeutic management of measles is described in details, including indications for hospital admission, etiotropic therapy, strict indications for steroids and immunoglobulins prescription, vitamin A in dosages, therapy of complications, indications for antibiotics usage and other pathogenetic therapy. Specific therapy of measles complications from central nervous system is outlined. Active and passive immunization, anti-epidemic activities, patient follow-up after episode of measles and disease prognosis are described. The literature reference list consists of 121 items, including Cyrillic, Latin articles and electronic resources.

The impact of type 2 diabetes mellitus on mortality in hospitalized female cancer patients in Taiwan

The goal of this study was to determine the relationships among type 2 diabetes mellitus (DM), specific cancer histological types and mortality in hospitalized women. Patients over 19 years of age were included if the indication for hospital admission was a diagnosis of type 2 DM or a malignancy. In total, 67,660 female patients with a mean age 62.76 ± 14.48 years were enrolled. These patients were categorized into the following three groups: patients with cancer but without type 2 DM (group A); patients with cancer and type 2 DM (group B) and patients with type 2 DM but without cancer (group C). Attributable fractions (AF) were calculated as ([hazard ratio - 1]/hazard ratio) × 100 to evaluate the impact of type 2 DM on mortality for specific cancers. Of the study participants, 37,204 (55%) were diagnosed with type 2 DM. The patients were categorized as follows: group A, 30,456 patients; group B, 5992 patients and group C, 31,212 patients. Group B patients had high frequencies of pancreatic, liver and renal cancers and low frequencies of thyroid, breast and ovarian cancers. Of the 36,448 cancer patients, 2906 (8%) died. The mortality rate in group B (10 %) was significantly higher than that in groups A and C. Type 2 DM was associated with increased mortality and AF for thyroid, nasopharyngeal, urinary tract, ovarian, breast and cervical cancers (hazard ratio over 1.50). The incidence of type 2 DM in patients with different histological types of cancer varied widely, ranging from 8-34%. Among the cancer patients, type 2 DM had a significantly greater impact on the mortality rates of patients with cancers associated with relatively low mortality.

Hospital Admission Decision for Patients with Community-Acquired Pneumonia

Where to treat patients is probably the single most important decision in the management of community-acquired pneumonia (CAP), with a substantial impact on both patients' outcomes and health-care costs. Several factors can contribute to the decision of the site of care for CAP patients, including physicians' experience and clinical judgment and severity scores developed to predict mortality, as well as social and health-care-related issues. The recognition, both in the community and in the emergency department, of the presence of severe sepsis and acute respiratory failure and the coexistence with unstable comorbidities other than CAP are indications for hospital admission. In all the other cases, physician's choice to admit CAP patients should be validated against at least one objective tool of risk assessment, with a clear understanding of each score's limitations.

Clinical use, diagnostic efficiency and impact on patient management of cardiovascular magnetic resonance

Background To evaluate the clinical use, diagnostic efficiency and impact on patient management of cardiovascular magnetic resonance (CMR). Methods Data of the individual patient as well as procedural information of 2598 consecutive clinically indicated CMR exams were prospectively collected in a single CMR center. For a representative subgroup of 250 exams, an external blinded reviewer evaluated the need for diagnostic tests and hospitalization before and after the CMR exam and assessed the impact of CMR on patient management. Results CMR was used in a large variety of indications, with inflammatory (29.4%) and ischemic (26.2%) heart disease as the most frequent. All moderate adverse events (0.5%) were associated with stress medication or contrast media. In subgroup analysis, CMR ruled out a suspected disease in 63.1%, confirmed a suspected or known disease in 27.8% or detected an unexpected new pathology in 7.2%. The clinical question was answered completely or partially in 88.4% and 11.2%, respectively. CMR reduced the amount of other diagnostic tests by 65.7% and changed the diagnostic strategy for the individual patient in 92.4%. For instance, 11/36 (30.6%) of the subjects who should initially undergo heart catheterization did not require this invasive study subsequent to the CMR. In contrast, 12/214 (5.6%) of the patients required heart catheterization based on the CMR findings, even though they were not scheduled for heart catheterization initially. In 23.6%, CMR led to a strategic change between in- or outpatient treatment. Conclusions CMR is safe, robust and versatile. It influences the indication for hospital admission, the choice and extent of individual downstream diagnostic testing, and the determination of the final diagnosis. Funding

Ambulatory management of pulmonary embolism: a pragmatic evaluation.

Patients diagnosed with pulmonary embolism should be considered for treatment on an outpatient basis; however, this practise is not accepted in many centers. Review the safety and efficacy of ambulatory management of patients with pulmonary embolism at our institution. This was a retrospective single center cohort study of consecutive patients diagnosed with idiopathic or secondary pulmonary embolism between January 2003 and January 2008 at the London Health Sciences Centre in London, Ontario, Canada. Patients were eligible for outpatient management of pulmonary embolism if they were hemodynamically stable, did not require oxygen therapy, did not require parenteral narcotics for pain management, and were not felt to be high risk for a major hemorrhage. Patients were assessed at 3 months for thrombosis recurrence and major bleeding episodes. Six hundred and thirty-nine patients were included in the study, of which 314 (49.1%; 95% CI 45.2, 53.1) were managed as outpatients; among these there were three (0.95%; 95% CI, 0.25, 3) thrombotic recurrences and three hemorrhagic events. There were nine deaths (2.9%; 95% CI, 1.4, 5.6), all due to underlying cancer and all occurring after the first 7 days of treatment. Outpatient management of uncomplicated pulmonary embolism seems safe and effective in the absence of other indications for hospital admission.

Safe Treatment of Pulmonary Embolism on An Outpatient Basis.

Background: Acute pulmonary embolism (PE) is a common medical problem in outpatient clinics and emergency rooms. Treatment with heparin and warfarin is well established and effective. In some centres (such as ours) eligible patients with PE are treated as outpatients, however many centres remain reluctant to do so. We review our experience with outpatient treatment of acute PE.Methods: We reviewed hospital charts for all inpatients and thrombosis clinic charts for all outpatients with a diagnosis of acute PE that was made prior to a decision on hospital admission from January 1, 2003 to January 30, 2008. All diagnoses were objectively proven by high probability V/Q scan or non-diagnostic V/Q scan with positive compression U/S or segmental or greater perfusion defect on CTPA. Patients were eligible to be treated as outpatients if they were hemodynamically stable, not high risk for bleeding, not requiring oxygen therapy, not requiring unfractionated heparin due to renal failure, and not having another indication for hospital admission. Most patients were treated with low molecular weight heparin (LMWH) for 5–7 days together with warfarin except for cancer patients who were treated with LMWH alone. All patients were instructed to call the thrombosis service or to go the emergency room if they developed symptoms of new PE or bleeding. Outpatients were seen in follow-up at 1, 4, and 12 weeks in the thrombosis clinic. Inpatient charts were reviewed for demographics and reason for hospital admission. For outpatients, in addition to demographics, charts were reviewed for the three month outcomes of major bleeding, recurrent venous thromboembolism and death.Results: There were a total of 633 patients with PE. 319 were admitted to the hospital whereas 314 (49.7%) were managed entirely as outpatients. The mean age for inpatients was 64 years. Inpatients were admitted for the following reasons: 125 (39%) for concomitant illness, 84 (26%) for hypoxia, 21 (7%) for hemodynamic instability, 14 (4%) for pain control, 1 (0.3%) for thrombolysis, 24 (7%) for other investigations, and 50 (16%) for other or unlcear reasons. For the 314 outpatients the mean age was 55 years and 184 (59%) were female. Eight (2.8%) patients were lost to follow-up. There were 195 (62%) idiopathic PE, 62 (20%) had PE secondary to cancer and 57(18%) to other transient risk factors. There were 247 (79%) patients who were managed with LMWH and warfarin, 51 (16%) managed with LMWH alone and 16 (5%) patients had experimental treatment. At 3 months of follow up there were 3 (1%) patients who developed major hemorrhage (GI bleed, hemoptysis, hemarthrosis), 3 (1%) patients who had objectively documented recurrent thrombosis (1 deep vein thrombosis, 2 PE), and 9 (2.9%) patients died, all of them from cancer progression. None of these events occurred within the first 7 days after diagnosis.Conclusions: To our knowledge this is the largest report of outpatient PE management. In our hospital 50% of ambulatory patients who have a diagnosis of PE are managed entirely as outpatients with a low risk for bleeding or thrombosis recurrence. For those admitted the majority was due to a concomitant illness that required admission itself. Many centres remain hesitant to treat patients with PE in this fashion but will treat patients with deep vein thrombosis as outpatients. Both conditions are at risk of recurrent PE and bleeding but it is not clear how a hospital admission would prevent that from happening. Our findings suggest that uncomplicated PE is not an indication for hospital admission per se. Outpatient management of PE deserves further consideration.