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PurposeClinical decision rules for the disposition of patients with pulmonary embolism (PE) are typically validated against an outcome of 30-day mortality or disease recurrence. There is little justification for this time frame, nor is it clear whether this outcome reflects emergency department (ED) decision making.AimsTo determine which outcomes emergency physicians (EP) consider most relevant to disposition decisions.MethodsSurvey of attending EPs in geographically diverse US states using acute PE as the diagnostic framework. Responses required single-answer multiple choice, a numerical percentage, rank-ordered responses, or a five-point Likert scale. We distributed the survey via e-mail to 608 EPs.ResultsWe received responses from 292 (48%) EPs: 88% board certified, 91% trained in emergency medicine, and 70% work in academics. Respondents reported discharging 1% of patients with PE from the ED, but 21% reported being asked to do so by an admitting service. EPs were more interested in knowing 5-day (in hospital) outcomes [192/265, 72% (95% exact CI = 66%–78%)] than 30-day outcomes [39/261, 15% (95% exact CI = 11%–20%)] or 90-day outcomes [29/263, 11% (95% exact CI = 8%–15%)]. On a Likert scale, 212/241 (88%, 95% exact CI = 83%–92%) agreed or strongly agreed that they considered 5-day (in hospital) clinical deterioration when making a decision to admit or discharge a patient from the ED compared to 184/242 (76%, 95% exact CI = 70%–81%) and 73/242 (30%, 95% exact CI = 24%–36%) for 30 and 90 days, respectively. A wide variety of clinical outcomes beyond death or recurrent PE were considered indicative of clinical deterioration.ConclusionsFive-day (in hospital) outcomes that incorporate a variety of clinical deterioration events are of interest to EPs when determining the disposition of ED patients with PE. Researchers should consider this when developing and validating clinical decision rules.

A novel member of human RNA coronavirus, which is an enveloped betacoronavirus, has been termed severe acute respiratory syndrome coronavirus-2 (SARS COV-2). The illness caused by SARS COV-2 is referred to as the coronavirus disease 2019 (COVID-19). It is a highly contagious disease that has resulted in a global pandemic. The clinical spectrum of COVID-19 ranges from asymptomatic illness to acute respiratory distress syndrome, septic shock, multi-organ dysfunction, and death. The most common symptoms include fever, fatigue, dry cough, dyspnea, and diarrhea. Neurological manifestations have also been reported. However, the data on the association of Guillain-Barré syndrome (GBS) with COVID-19 are scarce. We report a rare case of a COVID-19-positive 36-year-old immunocompromised male who presented with clinical features of GBS. His clinical examination showed generalized weakness and hyporeflexia. The cerebrospinal fluid (CSF) analysis showed albuminocytological dissociation. Intravenous immunoglobulin (IVIG) was administered based on the high clinical suspicion of GBS. The patient’s neurological condition worsened with progression to bulbar weakness and ultimately neuromuscular respiratory failure requiring mechanical ventilation. His nerve conduction studies were consistent with demyelinating polyneuropathy. He received five plasma exchange treatments and was successfully weaned from mechanical ventilation. A brain and cervical spine magnetic resonance imaging was obtained to rule out other causes, which was normal. COVID-19 is believed to cause a dysregulated immune system, which likely plays an important role in the neuropathogenesis of GBS.

In acute PE, CT is highly sensitive but only moderately specific for RVS compared to TTE. RVS on both CT and TTE predicts more events than either modality alone. TTE confers additional positive prognostic value compared to CT in predicting post-PE clinical deterioration.

The Pulmonary Embolism Severity Index (PESI) has been shown to predict 30 and 90 day mortality after PE. However, whether the PESI predicts patients who will be free of clinically adverse outcomes during a typical hospitalisation is not known. Retrospective analysis of Emergency Department patients with PE from May 2006 to April 2008. We compiled demographics, data to calculate the PESI and a composite outcome. Patients were considered to have a negative PESI if they were in category I or II (≤85 points). Patients were considered to have the composite outcome if, within five days of diagnosis, they: A) had recurrent PE; B) developed a new cardiac dysrhythmia; C) required advanced cardiac life support; D) required respiratory support; E) required vasopressors; F) received thrombolysis; G) had major bleeding; H) returned to the ED; I) died. We enrolled 245 patients with PE. Of these, 115 (47%) were male, 204 (83%) were white. The mean age was 57 ± 17 years. The PESI identified 109 (44%) as low risk and 136 (56%) as high risk. Sixty-one (26%) patients had the outcome, of whom nine (14%) were characterised as low risk by the PESI. Test characteristics were: sensitivity 86% (95% confidence interval [CI]: 75%-93%), specificity 55% (95% CI: 47%-62%), NPV 63% (95% CI: 55%-70%), PPV 40% (95% CI: 31%-49%), LR(+) 1.9 (95% CI: 1.57-2.30) and LR(-) 0.26 (95% CI: 0.14-0.48). Of the patients who had an adverse clinical event or required a hospital-based intervention within the first five days after PE diagnosis, 14% were categorised by the PESI as safe for discharge [corrected] .

Concerning inter-visit repeatability, the data from 56 subjects with CF (adult and children) exhibited stability across the two measurements, with no significant difference between LCI measurements (paired t test, P ¼ .80). 1 The mean %CV for visit 1 (4.3%) and visit 2 (4.7%) were also not significantly different (paired t test, P ¼ .21). These results were comparable to the intra-visit %CV reported in the larger cohort of adults and children with CF. Figure 2 presents the limits of agreement between visits, which equates to a CoR of 1.4. These data underline our findings that LCI has good short-and long-term repeatability in CF but highlights that variability is greater in disease compared with health. These results emphasize that sample size estimates should be informed by CF data (and not by HC data) to avoid study underpowering. In our study, variability was comparable in children and adults with CF in contrast to some evidence that shows increased variation with disease severity and/or age. 3,4 Using %CV, CoR, and Bland-Altman statistics to assess inter-visit repeatbility, our combined child and adult CF data across 2 stable visits show levels of variation similar to those reported in the intra-visit data. We hope that this additional analysis can provide further insight into the natural variability of LCI across the age range in CF and help inform the question of what is a clinically meaningful change in LCI.

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