Background: Acute PE is rapidly fatal if not diagnosed and treated. Studies have shown that intravenous heparin improves overall survival for patients with PE, and therapeutic anticoagulation reduces rates of recurrent VTE. However, studies investigating the relation between time to achieve therapeutic anticoagulation and mortality or PE recurrence are limited.
Study design: Retrospective cohort study.
Setting: Mayo Clinic, Rochester, Minn.
Synopsis: From June 2002 and September 2005, 400 patients were identified with PE using retrospective data from Mayo Clinic’s electronic medical records. Patients who received heparin in the ED had lower in-hospital mortality (OR 0.20, 95% CI, 0.06-0.69) and 30-day mortality (OR 0.25, 95% CI, 0.12-0.55) compared with patients who received heparin after admission. Similarly, patients who achieved a therapeutic aPTT within 24 hours also had lower 30-day mortality (OR 0.34, 95% CI, 0.14-0.84). Patients with COPD and malignancies had higher in-hospital and 30-day mortality, respectively.
Bottom line: It is difficult to draw a causal relationship from a retrospective review, but hospitalists should start immediate anticoagulation therapy when a PE is suspected.
Citation: Smith SB, Geske JB, Maguire JM, Zane NA, Carter RE, Morgenthaler TI. Early anticoagulation is associated with reduced mortality for acute pulmonary embolism. Chest. 2010;137(6): 1382-1390. TH
PEDIATRIC HM LITERATURE
Ibuprofen Use Associated with Complicated Pneumonia
Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.
Clinical question: What baseline characteristics are associated with suppurative complications in children hospitalized with community-acquired pneumonia?
Background: The prevalence of suppurative complications of community-acquired pneumonia (CAP) appears to be on the rise. Reasons for this increase remain unclear, although etiologic organism, older age, prior antibiotic, and nonsteroidal anti-inflammatory drug use have been implicated in a single prior retrospective study.
Study design: Retrospective cohort study.
Setting: Two hospitals in France.
Synopsis: Two physicians reviewed 1,184 charts based on ICD-10 discharge codes for pneumonia from 1995 to 2003. Children younger than 28 days and older than 15 years were excluded. Additionally, children with underlying or cardiorespiratory pathology were excluded. After applying predefined clinical criteria for pneumonia and suppurative complications, 677 children with CAP were compared to 90 with suppurative complications of pneumonia.
The incidence of suppurative complications increased to 13 per 100,000 from 0.5 per 100,000 over the time period. A minority of patients had etiologic microbes isolated, primarily Streptococcus pneumoniae, in both groups. Complicated pneumonia was more frequently seen in older children, and in children with prior antibiotic and anti-inflammatory medication use. After multivariable analysis, only ibuprofen use remained with an increased odds ratio (2.57, 95% confidence interval, 1.51-4.35) of complicated pneumonia.
The clear drawback of this study is an inability to draw a causal connection between ibuprofen use and the development of suppurative complications of pneumonia. The retrospective nature of the analysis further limits hypothesis generation. Nevertheless, it is notable that the results corroborate findings from a prior study in the U.S., in which ibuprofen was found to significantly increase the likelihood of parapneumonic empyema.
Bottom line: Ibuprofen use is associated with the development of suppurative complications of pneumonia.
Citation: François P, Desrumaux A, Cans C, Pin I, Pavese P, Labarère J. Prevalence and risk factors of suppurative complications in children with pneumonia. Acta Paediatr. 2010;99(6):861-866.