Prognosis

D-dimer levels for Risk Stratification in Patients with Suspected COVID-19 – A Prospective Observational Study

Original Articles, Volume 20, Issue 3, Pages 157-248 (2021)

Background: Elevated D-dimer levels have been observed in COVID-19 and are of prognostic value, but have not been compared to an appropriate control group.
Methods: Observational cohort study including emergency patients with suspected or confirmed COVID-19. Logistic regression defined the association of D-dimer levels, COVID-19 positivity, age, and gender with 30-day-mortality.
Results: 953 consecutive patients (median age 58, 43% women) presented with suspected COVID-19: 12 (7.4%) patients with confirmed SARS-CoV-2-infection died, compared with 28 (3.5%) patients without SARS-CoV-2-infection. Overall, most (56%) patients had elevated D-dimer levels (≥0.5mg/l). Age (OR 1.07, CI 1.05-1.10), D-dimer levels ≥0.5mg/l (OR 2.44, CI 0.98-7.39), and COVID-19 (OR 2.79, CI 1.28-5.80) were associated with 30-day-mortality.
Conclusion: D-dimer levels are effective prognosticators in both patient groups.

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Evaluation of systemic vasoconstriction and prognosis using thermography: a systematic review

Clinical Reviews, Volume 20, Issue 2, Pages 89-156 (2021)

Purpose: This systematic review investigates whether infrared thermography (IRT) can measure systemic vasoconstriction and addresses the value of IRT in assessing circulatory deficiency and prognoses.

Methods: Design was based on the PRISMA criteria and a systematic search of 6 databases was performed.

Results: Of 3,198 records, five articles were included. Three clinical studies were identified; two found significant correlations between IRT obtained temperatures and mortality. An experimental study found an association between peripheral temperature and stroke volume. An animal study found that central-peripheral temperature differences correlated with shock index, mean arterial pressure, and disease progression.

Conclusions: Data from the most valid study suggests that central-peripheral temperature differences should be investigated further, both on its own, and integrated with other variables.

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Correlating pulmonary embolism severity with short term mortality to risk stratify for outpatient management

Original Articles, Volume 19, Issue 2, Pages 61 – 112 (2020)

Aims: We ascertain less than 7-day mortality data in suspected pulmonary embolism (PE) in order to risk stratify patients suitable for outpatient imaging.

Methods: Retrospective identification of patients presenting to two emergency departments over a two-year period, with a radiologically confirmed PE. PESI and sPESI scores correlated with death at 1, 3, 7, 30 and 90 days.

Results: There was significant correlation between all PESI risk classes and death at 3, 7, 30 and 90 days (p<0.01), but not day 1. No deaths occurred within 1 and 3 days in low risk PESI groups or within 90 days in the low risk sPESI. Conclusion: PESI/sPESI could be reliably utilized to risk stratify patients being considered for outpatient investigation of PE.

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Prediction models for mortality in adult patients visiting the Emergency Department: a systematic review

Clinical Reviews, Volume 18, Issue 3, Pages 137 – 204 (2019)

We provide a systematic overview of literature on prediction models for mortality in the Emergency Department (ED). We searched various databases for observational studies in the ED or similar setting describing prediction models for short-term mortality (up to 30 days or in-hospital mortality) in a non-trauma population. We used the CHARMS-checklist for quality assessment. We found a total of 14.768 articles and included 17 articles, describing 22 models. Model performance ranged from AUC 0.63- 0.93. Most articles had a moderate risk of bias in one or more domains. The full model and PARIS model performed best, but are not yet ready for implementation. There is a need for validation studies to compare multiple prediction models and to evaluate their accuracy.

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What is the evidence base for ambulatory care for acute medical illness?

Review Articles, Volume 17, Issue 3, Pages 117 – 172 (2018)

Acute ambulatory care is a critical component of the emergency care pathway with national policy support and a dedicated NHS Improvement network. The evidence base for treating acute medical illness outside hospital is a diverse mix of randomised and observational studies with varying inclusion criteria, prognostic stratification, interventions and healthcare setting which limits synthesis of all available evidence and translation to the UK context. There is little consensus on the level of risk for home-based treatment for acute medical illness. Selection tools for referral to acute ambulatory care have been developed but there is limited evidence for their use. There are still research questions concerning optimal staffing, referral mechanisms, point of care diagnostic portfolio and tools for shared decision making.

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