Assembling the Puzzle: Taking into Account Clinical Presentation and Predictive Scores

Syncope is a common cause of emergency department visits. Physicians must scrutinize for life-threatening causes to avoid patient morbidity and mortality. Clinical decision rules are used to stratify risks and guide the course of action, including the need for further testing. This is the case of a 83-year-old man was brought to the emergency department after a 5-minute episode of sudden loss of consciousness. Vital signs showed hypotension and physical examination was unremarkable. Despite Wells score of 0, clinical suspicion for pulmonary embolism persisted, for which further testing was pursued. D-dimer was elevated at 13.77 mcg/mL and a chest computed tomography with angiography showed an extensive bilateral pulmonary embolism involving the distal right and left main pulmonary arteries. He was started on full-dose anticoagulation. This case exemplifies the need of high clinical suspicion along with the importance of applying predictive scores for diagnosing unusual causes of syncope.

Prognostic factors of inhospital death in elderly patients: a time-to-event analysis of a cohort study in Martinique (French West Indies)

OBJECTIVE

The primary objective was to identify predictive factors of inhospital death in a population of patients aged 65 years or older hospitalised with Chikungunya virus (CHIKV) infection. The secondary aim was to develop and validate a predictive score for inhospital death based on the predictors identified.

DESIGN

Longitudinal retrospective study from January to December 2014.

SETTING

University Hospital of Martinique.

PARTICIPANTS

Patients aged ≥65 years, admitted to any clinical ward and who underwent reverse transcription PCR testing for CHIKV infection.

OUTCOME

Independent predictors of inhospital death were identified using multivariable Cox regression modelling. A predictive score was created using the adjusted HRs of factors associated with inhospital death. Receiver operating characteristic curve analysis was used to determine the best cut-off value. Bootstrap analysis was used to evaluate internal validity.

RESULTS

Overall, 385 patients aged ≥65 years were included (average age: 80±8 years). Half were women, and 35 (9.1%) died during the hospital stay. Seven variables were found to be independently associated with inhospital death (concurrent cardiovascular disorders: HR 11.8, 95% CI 4.5 to 30.8; concurrent respiratory infection: HR 9.6, 95% CI 3.4 to 27.2; concurrent sensorimotor deficit: HR 7.6, 95% CI 2.0 to 28.5; absence of musculoskeletal pain: HR 2.6, 95% CI 1.3 to 5.3; history of alcoholism: HR 2.5, 95% CI 1.1 to 5.9; concurrent digestive symptoms: HR 2.4, 95% CI 1.2 to 4.9; presence of confusion or delirium: HR 2.1, 95% CI 1.1 to 4.2). The score ranged from 0 to 25, with an average of 6±6. The area under the curve was excellent (0.90; 95% CI 0.86 to 0.94). The best cut-off value was a score ≥8 points, with a sensitivity of 91% (82%-100%) and specificity of 75% (70%-80%).

CONCLUSIONS

Signs observed by the clinician during the initial examination could predict inhospital death. The score will be helpful for early management of elderly subjects presenting within 7 days of symptom onset in the context of CHIKV outbreaks.