Purpose To determine the effectiveness of MR angiography for pulmonary embolism (MRA-PE) in symptomatic patients. Materials and Methods We retrospectively reviewed all patients whom were evaluated for possible pulmonary embolism (PE) using MRA-PE. A 3-month and 1-year from MRA-PE electronic medical record (EMR) review was performed. Evidence for venous thromboembolism (VTE) (or death from PE) within the year of follow-up was the outcome surrogate for this study. Results There were 190 MRA-PE exams performed with 97.4% (185/190) of diagnostic quality. There were 148 patients (120 F: 28 M) that had both a diagnostic MRA-PE exam and 1 complete year of EMR follow-up. There were 167 patients (137 F: 30 M) with 3 months or greater follow-up. We found 83% (139/167) and 81% (120/148) MRA-PE exams negative for PE at 3 months and 1 year, respectively. Positive exams for PE were seen in 14% (23/167). During the 1-year follow-up period, five patients (false negative) were diagnosed with DVT (5/148 = 3.4 %), and one of these patients also experienced a non–life-threatening PE. The negative predictive value (NPV) for MRA-PE was 97% (92–99; 95% CI) at 3 months and 96% (90–98; 95% CI) with 1 year of follow-up. Conclusion The NPV of MRA-PE, when used for the primary diagnosis of pulmonary embolism in symptomatic patients, were found to be similar to the published values for CTA-PE. In addition, the technical success rate and safety of MRA-PE were excellent.

Purpose To evaluate the effects of a palliative care intervention on clinical and family outcomes, and palliative care processes. Methods Prospective, before-and-after interventional study enrolling patients with high risk of mortality, morbidity, or unmet palliative care needs in a 24-bed academic intensive care unit (ICU). The intervention involved a palliative care clinician interacting with the ICU physicians on daily rounds for high-risk patients. Results 100 patients were enrolled in the usual care phase, and 103 patients were enrolled during the intervention phase. The adjusted likelihood of a family meeting in ICU was 63% higher (RR 1.63, 95% CI 1.14 to 2.07, p=0.01), and time to family meeting was 41% shorter (95% CI 52% to 28% shorter, p<0.001). Adjusted ICU length of stay (LOS) was not significantly different between the two groups (6% shorter, 95% CI 16% shorter to 4% longer, p=0.22). Among those who died in the hospital, ICU LOS was 19% shorter in the intervention (95% CI 33% to 1% shorter, p=0.043). Adjusted hospital LOS was 26% shorter (95% CI 31% to 20% shorter, p < 0.001) with the intervention. PTSD symptoms were present in 9.1% of family respondents during the intervention versus 20.7% prior to the intervention (p=0.09). Mortality, family depressive symptoms, family satisfaction and quality of death and dying did not significantly differ between groups. Conclusions Proactive palliative care involvement on ICU rounds for high-risk patients was associated with more and earlier ICU family meetings and shorter hospital LOS. We did not identify differences in family satisfaction, family psychological symptoms, or family-rated quality of dying, but had limited power to detect such differences.

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Objective To determine whether clinical scoring systems or physician gestalt can obviate the need for CT in patients with possible appendicitis. Methods Prospective, observational study of patients with abdominal pain at an academic emergency department from 2/2012–2/2014. Patients over 11 years old who had a CT ordered for possible appendicitis were eligible. All parameters needed to calculate the scores were recorded on standardized forms prior to CT. Physicians also estimated the likelihood of appendicitis. Test characteristics were calculated using clinical follow up as the reference standard. ROC curves were drawn. Results Of the 287 patients (mean age [range], 31 [12–88] years; 60% women), the prevalence of appendicitis was 33%. The Alvarado score had a positive likelihood ratio [LR(+)] (95% confidence interval) of 2.2 (1.7–3) and a negative likelihood ratio [LR(−)] of 0.6 (0.4–0.7). The modified Alvarado score (MAS) had LR(+) 2.4 (1.6–3.4) and LR(−) 0.7 (0.6–0.8). The RIPASA score had LR(+) 1.3 (1.1–1.5) and LR(−) 0.5 (0.4–0.8). Physician-determined likelihood of appendicitis had LR(+) 1.3 (1.2–1.5) and LR(−) 0.3 (0.2–0.6). When combined with physician likelihoods, LR(+) and LR(−) was 3.67 and 0.48 (Alvarado), 2.33 and 0.45 (RIPASA), and 3.87 and 0.47 (MAS). The AUC was highest for physician-determined likelihood (0.72), but was not statistically significantly different from the clinical scores (RIPASA – 0.67, Alvarado 0.72, MAS 0.7). Conclusions Clinical scoring systems performed equally well as physician gestalt in predicting appendicitis. These scores do not obviate the need for imaging for possible appendicitis when a physician deems it necessary.

Background: Machine learning is increasingly used for risk stratification in healthcare. Achieving accurate predictive models does not improve outcomes if they cannot be translated into efficacious intervention. Here we examine the potential utility of an automated risk-stratification and referral intervention to screen older adults for fall risk after ED visits. Objective: This study evaluated several machine learning methodologies for the creation of a risk stratification algorithm using electronic health record (EHR) data, and estimated the effects of a resultant intervention based on algorithm performance in test data. Methods: Data available at the time of ED discharge was retrospectively collected and separated into training and test datasets. Algorithms were developed to predict the outcome of return visit for fall within 6 months of an ED index visit. Models included random forests, AdaBoost, and regression-based methods. We evaluated models both by area under the receiver operating