D-dimer levels and 15-day outcome in acute pulmonary embolism. Findings from the RIETE Registry.

BACKGROUND: A number of variables have been evaluated for risk stratification in patients with acute pulmonary embolism (PE). Whereas increased D-dimer levels have been associated with mortality at 3 months, its role in predicting short-term outcome (the period of time during which any therapeutic decision has to be taken) remains unclear. METHODS: RIETE is an ongoing, prospective registry of consecutive patients with acute venous thromboembolism. We assessed the prognostic value of D-dimer levels at baseline, measured with an automated latex agglutination test (IL Test D-dimer), on the 15-day outcome in patients with acute PE. Overall mortality, fatal PE and major bleeding rates were compared by quartile. RESULTS: As of February 2008, 1707 patients with acute PE underwent D-dimer testing. Of these, 72 patients (4.2%) died during the first 15 days, 11 (0.6%) had recurrent PE, and 29 (1.7%) had major bleeding. Overall mortality increased with increasing D-dimer levels, from 2.7% in the first quartile (< 1050 ng mL(-1)) to 7.0% in the fourth quartile (>or= 4200 ng mL(-1)). The rates of fatal PE and major bleeding also increased. On multivariate analysis, patients with D-dimer levels in the fourth quartile had an increased risk for overall death (odds ratio, 1.8; 95% CI, 1.1-3.2), fatal PE (odds ratio, 2.0; 95% CI, 1.0-3.8) or major bleeding (odds ratio, 3.2; 95% CI, 1.5-7.0). CONCLUSIONS: PE patients with D-dimer levels in the fourth quartile had an increased incidence of overall death, fatal PE and major bleeding within 15 days both before and after multivariate adjustment.

[Evaluation of a computer predictive model to stratify risk and site of care in community acquired pneumonia]. / Utilidad de un modelo informatizado para estratificación de riesgo y decisión de lugar de tratamiento en la neumonía de la comunidad.

BACKGROUND: CAP is a common disorder with a great variability in clinical practice. The decision regarding the appropriate site of care is the most important for the level of treatment and costs. Recently a hospital in our region ( Hospital de Galdakao) developed a prediction rule based on the Pneumonia Severity Index (PSI) plus some additional criteria (hypoxemia <60, shock, previous correct treatment failure, social problems or inability to maintain oral intake, pleural effusion or unstable comorbidities) with an easy computer program to classify patients to be hospitalized or not. OBJECTIVE: Evaluate that computer program in the emergency department of our hospital. RESULTS: We included between December 02 and December 04,662 prospective patients with CAP admitted to our emergency department, 58 had a different final diagnosis. 285 (47%) were treated on outpatient basis. Readmission rate was 6%. There was no mortality in this group. 319 (53%) patients were hospitalized, 97 were PSI low risk patients (I-II), 61 of them were admitted to hospital because additional criteria. 45% of these "low risk patients" had significant complications. These results are similar to those obtained in Galdakao* CONCLUSIONS: The application of this computer risk stratifying program to assess admission to hospital in CAP is simple useful, secure and can be export to different settings. Additional criteria to PSI are necessary to detect low risk patients that complicate.

Utilidad de un modelo informatizado para estratificación de riesgo y decisión de lugar de tratamiento en la neumonía de la comunidad / Evaluation of a computer predictive model to stratify risk and site of care in community acquired pneumonia

Introducción: La neumonía adquirida en la comunidad (NAC) es una patología muy común y con una gran variabilidad en la práctica clínica. La decisión de hospitalizar o no a un paciente es la más importante en cuanto al nivel de tratamiento y costes. Recientemente un hospital de nuestra comunidad (Hospital de Galdakao) ha desarrollado una regla predictiva basada en el Pneumonia Severity Index (PSI), modificado por varios criterios adicionales (hipoxemia < 60, shock, fracaso de tratamiento previo correcto, problemas sociales o incapacidad para la ingesta oral, derrame pleural o comorbilidad inestable) mediante un sencillo programa informático para ayudar en la decisión de ingresar o no a un paciente. Objetivos: Evaluar la utilidad de ese programa informático en el servicio de urgencias de nuestro hospital. Resultados: Incluimos de forma prospectiva 662 pacientes con NAC que acudieron a urgencias del Hospital de Txagorritxu, entre Diciembre 2002 y Diciembre 2004. De ellos 58 tuvieron un diagnóstico final diferente. El 47% (285) fueron tratados de forma ambulatoria. La tasa de reingresos en este grupo fue del 6% y no hubo ningún éxitus. Fueron hospitalizados 319 pacientes, de ellos 97 pertenecían a clases de riesgo bajo del PSI, 61 de los cuales ingresaron por los criterios adicionales elegidos por nosotros, sufriendo el 45% de ellos complicaciones significativas. Estos resultados son similares a los obtenidos en el estudio del hospital de Galdakao. Conclusiones: La aplicación de este programa informático para estratificar riesgo y ayudar a la decisión de ingreso en la NAC es simple, útil, seguro y puede ser exportado a diferentes ámbitos clínicos. Son necesarios criterios adicionales al PSI para detectar los pacientes de bajo riesgo que tienen alguna complicación

Background: CAP is a common disorder with a great variability in clinical practice. The decision regarding the appropriate site of care is the most important for the level of treatment and costs. Recently a hospital in our region ( Hospital de Galdakao) developed a prediction rule based on the Pneumonia Severity Index (PSI) plus some additional criteria (hypoxemia <60, shock, previous correct treatment failure, social problems or inability to maintain oral intake, pleural effusion or unstable comorbidities) with an easy computer program to classify patients to be hospitalized or not. Objective: Evaluate that computer program in the emergency department of our hospital. Results: We included between December 02 and December 04 662 prospective patients with CAP admitted to our emergency department, 58 had a different final diagnosis. 285 (47%) were treated on outpatient basis. Readmission rate was 6%. There was no mortality in this group. 319 (53%) patients were hospitalized, 97 were PSI low risk patients (I-II), 61 of them were admitted to hospital because additional criteria. 45% of these “low risk patients” had significant complications. These results are similar to those obtained in Galdakao* Conclusions: The application of this computer risk stratifying program to assess admission to hospital in CAP is simple useful, secure and can be export to different settings. Additional criteria to PSI are necessary to detect low risk patients that complicate