Weekend versus weekday admission and mortality after acute pulmonary embolism.

BACKGROUND: Optimal management of acute pulmonary embolism (PE) requires medical expertise, diagnostic testing, and therapies that may not be available consistently throughout the entire week. We sought to assess whether associations exist between weekday or weekend admission and mortality and length of hospital stay for patients hospitalized with PE. METHODS AND RESULTS: We evaluated patients discharged with a primary diagnosis of PE from 186 acute care hospitals in Pennsylvania (January 2000 to November 2002). We used random-effect logistic models to study the association between weekend admission and 30-day mortality and used discrete survival models to study the association between weekend admission and time to hospital discharge, adjusting for hospital (region, size, and teaching status) and patient factors (race, insurance, severity of illness, and use of thrombolytic therapy). Among 15 531 patient discharges with PE, 3286 patients (21.2%) had been admitted on a weekend. Patients admitted on weekends had a higher unadjusted 30-day mortality rate (11.1% versus 8.8%) than patients admitted on weekdays, with no difference in length of stay. Patients admitted on weekends had significantly greater adjusted odds of dying (odds ratio 1.17, 95% confidence interval 1.03 to 1.34) than patients admitted on weekdays. The higher mortality among patients hospitalized on weekends was driven by the increased mortality rate among the most severely ill patients. CONCLUSIONS: Patients with PE who are admitted on weekends have a significantly higher short-term mortality than patients admitted on weekdays. Quality-improvement efforts should aim to ensure a consistent approach to the management of PE 7 days a week.

Sex differences in patients receiving anticoagulant therapy for venous thromboembolism.

In patients with venous thromboembolism (VTE), the outcome during the course of anticoagulant therapy may differ according to the patient's sex. We used the RIETE (Registro Informatizado Enfermedad TromboEmbólica) database to compare the rate of VTE recurrences, major bleeding, and mortality due to these events according to sex.As of August 2013, 47,499 patients were enrolled in RIETE, of whom 24,280 (51%) were women. Women were older, more likely presented with pulmonary embolism (PE), and were more likely to have recent immobilization but less likely to have cancer than men. During the course of anticoagulation (mean duration: 253 d), 659 patients developed recurrent deep vein thrombosis (DVT), 576 recurrent PE, 1368 bled, and 4506 died. Compared with men, women had a lower rate of DVT recurrences (hazard ratio [HR]: 0.78; 95% confidence interval [CI]: 0.67-0.91), a similar rate of PE recurrences (HR: 0.98; 95% CI: 0.83-1.15), a higher rate of major bleeding (HR: 1.21; 95% CI: 1.09-1.35), and higher mortality due to PE (HR: 1.24; 95% CI: 1.04-1.47). On multivariable analysis, any influence of sex on the risk for recurrent DVT (HR: 0.88; 95% CI: 0.75-1.03), major bleeding (HR: 1.10; 95% CI: 0.98-1.24), or fatal PE (HR: 1.01; 95% CI: 0.84-1.22) was no longer statistically significant.In conclusion, women had fewer DVT recurrences and more bleeds than men during the course of anticoagulation. These differences were not due to sex, but very likely to other patient characteristics more common in female patients and differences in treatment choice.

The pulmonary embolism rule-out criteria (PERC) rule does not safely exclude pulmonary embolism.

Background: The Pulmonary Embolism Rule-out Criteria (PERC) rule is a clinical diagnostic rule designed to exclude pulmonary embolism (PE) without further testing. We sought to externally validate the diagnostic performance of the PERC rule alone and combined with clinical probability assessment based on the revised Geneva score. Methods: The PERC rule was applied retrospectively to consecutive patients who presented with a clinical suspicion of PE to six emergency departments, and who were enrolled in a randomized trial of PE diagnosis. Patients who met all eight PERC criteria [PERC(-)] were considered to be at a very low risk for PE. We calculated the prevalence of PE among PERC(-) patients according to their clinical pretest probability of PE. We estimated the negative likelihood ratio of the PERC rule to predict PE. Results: Among 1675 patients, the prevalence of PE was 21.3%. Overall, 13.2% of patients were PERC(-). The prevalence of PE was 5.4% [95% confidence interval (CI): 3.1-9.3%] among PERC(-) patients overall and 6.4% (95% CI: 3.7-10.8%) among those PERC(-) patients with a low clinical pretest probability of PE. The PERC rule had a negative likelihood ratio of 0.70 (95% CI: 0.67-0.73) for predicting PE overall, and 0.63 (95% CI: 0.38-1.06) in low-risk patients. Conclusions: Our results suggest that the PERC rule alone or even when combined with the revised Geneva score cannot safely identify very low risk patients in whom PE can be ruled out without additional testing, at least in populations with a relatively high prevalence of PE.

Hyponatremia and short-term outcomes in patients with acute pulmonary embolism

BACKGROUND: Hyponatremia, a marker of neurohormonal activation, is associated with poor outcomes in acute cardiorespiratory diseases such as myocardial infarction, right and left ventricular heart failure, and pneumonia. The prognostic value of hyponatremia in patients with acute pulmonary embolism (PE) is unknown. We sought to assess whether hyponatremia at presentation was associated with mortality and hospital readmission in patients hospitalized with PE. METHODS: We studied patient discharges with a primary diagnosis of PE from 185 acute care hospitals in Pennsylvania (1/2000-11/2002). We defined hyponatremia as a serum sodium level ≤135 mmol/l, measured at the time of patient presentation. The study outcomes were 30-day all-cause mortality and hospital readmission. We used random-intercept logistic regression to examine the association between hyponatremia and mortality. We adjusted for baseline patient (race, insurance, severity of illness using the Pulmonary Embolism Severity Index) and hospital characteristics (region, hospital size and teaching status). We used the same approach to examine the association between hyponatremia and readmission among patients who were discharged alive. RESULTS: Among 13,728 patient discharges with PE, 2907 (21.1%) had hyponatremia at the time of presentation. Patients with hyponatremia were older (P<0.001) and more likely to have a history of cancer (P<0.001), heart failure (P<0.001), or chronic lung disease (P=0.002) than patients without hyponatremia. Patients with hyponatremia had a higher unadjusted cumulative 30-day mortality (15.2% vs 8.0%;P<0.001) and readmission rate (15.9% vs 11.8%; P< 0.001) than patients without hyponatremia (Figure). After adjustment for race, insurance, severity of illness, and hospital factors, hyponatremia was associated with a significantly greater odds of death (OR 1.71, 95% CI: 1.50-1.95) and hospital readmission (OR 1.29, 95% CI: 1.14-1.46). CONCLUSIONS: In this large, statewide sample of unselected patients with acute PE, hyponatremia was relatively common and was an independent predictor of short-term mortality and hospital readmission. Given that sodium is a low-cost, easily available laboratory parameter, it may be potentially useful in risk-stratifying patients with PE.

Fatal Events in Cancer Patients Receiving Anticoagulant Therapy for Venous Thromboembolism.

In cancer patients treated for venous thromboembolism (VTE), including deep-vein thrombosis (DVT) and pulmonary embolism (PE), analyzing mortality associated with recurrent VTE or major bleeding is needed to determine the optimal duration of anticoagulation.This was a cohort study using the Registro Informatizado de Enfermedad TromboEmbólica (RIETE) Registry database to compare rates of fatal recurrent PE and fatal bleeding in cancer patients receiving anticoagulation for VTE.As of January 2013, 44,794 patients were enrolled in RIETE, of whom 7911 (18%) had active cancer. During the course of anticoagulant therapy (mean, 181 ± 210 days), 178 cancer patients (4.3%) developed recurrent PE (5.5 per 100 patient-years; 95% CI: 4.8-6.4), 194 (4.7%) had recurrent DVT (6.2 per 100 patient-years; 95% confidence interval [CI]: 5.3-7.1), and 367 (8.9%) bled (11.3 per 100 patient-years; 95% CI: 10.2-12.5). Of 4125 patients initially presenting with PE, 43 (1.0%) died of recurrent PE and 45 (1.1%) of bleeding; of 3786 patients with DVT, 19 (0.5%) died of PE, and 55 (1.3%) of bleeding. During the first 3 months of anticoagulation, there were 59 (1.4%) fatal PE recurrences and 77 (1.9%) fatal bleeds. Beyond the third month, there were 3 fatal PE recurrences and 23 fatal bleeds.In RIETE cancer patients, the rate of fatal recurrent PE or fatal bleeding was much higher within the first 3 months of anticoagulation therapy.

Gender differences in cancer patients with acute venous thromboembolism.

BACKGROUND: The outcome of cancer patients with acute venous thromboembolism (VTE) may differ according to gender. METHODS: We used the RIETE database to compare the rate of VTE (pulmonary embolism [PE] or deep vein thrombosis [DVT]) recurrences), major bleeding and mortality during the course of anticoagulation, according to gender. RESULTS: As of August 2014, 11,055 patients with active cancer were enrolled in RIETE, of whom 5,104 (46%) were women. During the course of anticoagulation (mean: 142 days), 505 patients developed recurrent VTE, 429 bled and 2730 died. Compared with men, women had a significantly lower rate of fatal bleeding (risk ratio [RR]: 0.69; 95% CI: 0.47-0.99) and death (RR: 0.90; 95% CI: 0.83-0.97), and a non-significantly lower rate of PE recurrences (RR 0.83; 95% CI: 0.65-1.06) and major bleeding (RR: 0.89; 95% CI: 0.74-1.08). CONCLUSIONS: During the course of anticoagulation, cancer women with VTE had a better outcome than men.

Simultaneous acute pulmonary embolism and isolated septal myocardial infarction in a young patient

While the overall incidence of myocardial infarction (MI) has been decreasing since 2000 [1], there is an increasing number of younger patients presenting with MI [2]. Few studies have focused on MI in very young patients, aged 35 years or less, as they only account for a minority of all patients with myocardial infarction [3]. According to the age category, MI differs in presentation, treatment and outcome, as illustrated in table 1. Echocardiography is considered mandatory according to scientific guidelines in the management and diagnosis of MI [4,5,6]. However, new imaging techniques such as cardiac magnetic resonance (CMR) and computed tomography (CT) are increasingly performed and enable further refinement of the diagnosis of MI. These techniques allow, in particular, precise location and quantification of MI. In this case, MI was located to the septum, which is an unusual presentation of MI. The incidence of pulmonary embolism (PE) has also increased in young patients over the past years [7]. Since symptoms and signs of PE may be non-specific, establishing its diagnosis remains a challenge [8]. Therefore, PE is one of the most frequently missed diagnosis in clinical medicine. Because of the widespread use of CT and its improved visualization of pulmonary arteries, PE may be discovered incidentally [9]. In the absence of a congenital disorder, multiple and/or simultaneous disease presentation is uncommon in the young. We report the rare case of a 35 year old male with isolated septal MI and simultaneous PE. The diagnosis of this rare clinical entity was only possible by means of newer imaging techniques.

Between manualized treatments and principle-guided psychotherapy: illustration in the case of Caroline

My case study of "Caroline"-a 26 year old presenting with depression, PTSD symptoms, and a history of sexual abuse as a teenager-represents a "third way" between (1) a strict adherence to a manualized treatment, and (2) a principle-guided therapy, in which the therapy follows particular theoretical concepts, but depends on the therapist's clinical judgement to flexibly apply them to the individual case. Specifically, in my therapy with Caroline (Kramer, 2009), I employed Foa and Rothbaum's (1998) cognitive-behavioral, "Prolonged Exposure" (PE) manual for PTSD, but deviated from it in certain ways based upon my evaluation of Caroline's individualized goals and reactions using Grawe and Caspar's "Plan Analysis," which is a cross-theoretical model for assessment and treatment planning. In their commentaries on my case study of Caroline, Caspar (2009) and Haldimann-Balli (see Appendix in Kramer, 2009) support my use of this third way. On the other hand, the other commentators-Muller (2009) and Hembree and Brinen (2009)-critique my handling of the case, arguing that strict adherence to the Foa and Rothbaum manual would have resulted in a more cost-effective therapy. In this article, I respond to the important issues raised by the four commentators.

Alliance evolutions over the course of short-term dynamic psychotherapy: A case study

Background: Alliance evolutions, i.e. ruptures and resolutions over the course of psychotherapy, have been shown to be important descriptive features in different forms of psychotherapy, and in particular in psychodynamic psychotherapy. This case study of a client presenting elements of adjustment disorder undergoing short-term dynamic psychotherapy is drawn from a systematic naturalistic study and aims at illustrating, on a session-by-session-level, the processes of alliance ruptures and resolutions, by comparing both the client's and the therapist's perspectives. Method: Two episodes of alliance evolution were more fully studied, in relation to the evolution of transference, as well as the client's defensive functioning and core conflictual theme. These concepts were measured by means of valid, reliable observer-rater methods, based on session transcripts: the Defense Mechanisms Rating Scales (DMRS) for defensive functioning and the Core Conflictual Relationship Theme (CCRT) for the conflicts. Alliance was measured after each session using the Helping Alliance questionnaire (HAq-II). Results: The results indicated that these episodes of alliance rupture and resolutions may be understood as key moments of the whole therapeutic process reflecting the client's main relationship stakes. Illustrations are provided based on the client's in-session processes and related to the alliance development over the course of the entire therapy.

Change in defense mechanisms and coping over the course of short-term dynamic psychotherapy for adjustment disorder.

Short-term dynamic psychotherapy (STDP) has rarely been investigated with regard to its underlying mechanisms of change, even if psychoanalytic theory informs us about several potential putative mechanisms of change in patients. Change in overall defensive functioning is one. In this study, we explored the role of overall defensive functioning, by comparing it on the process level with the neighbouring concept of overall coping functioning. A total of N=32 patients, mainly presenting adjustment disorder, were included in the study. The patients underwent STDP up to 40 sessions; three sessions per psychotherapy were transcribed and analyzed by using two observer-rating scales: Defense Mechanism Rating Scales (Perry, 1990) and Coping Action Patterns (Perry, Drapeau, Dunkley, & Blake, 2005). Hierarchical linear modeling was applied to model the change over the course of therapy and relate it to outcome. Results suggest that STDP has an effect on the target variable of overall defensive functioning, which was absent for overall coping functioning. Links with outcome confirm the importance of the effect. These results are discussed from methodological and clinical viewpoints.

De l'importance de l'approfondissement de l'affect en psychothérapie = On the importance of deepening of affect in psychotherapy

Deepening of affect in psychotherapy is a process that allows the patient to access more fully his/her affective experience linked to the problems. This process allows him/her to better understand this experience, aiming at a new understanding of himself/herself, the internal determinants of the problem and his/her reactions to difficult situations. Four clinical models treat this question by proposing different techniques aiming at deepening of affect in session: brief psychodynamic psychotherapy, clinical hypnosis, emotion-focused therapy, clarification-oriented psychotherapy as development of focusing. It appears that, despite diverse theoretical approaches, there exist several parallels throughout these approaches. We will summarize the research results supporting the hypothesis of affect deepening as an efficacious therapeutic process in different forms of exploratory psychotherapy. (C) 2009 Societe francaise de psychologie. Published by Elsevier Masson SAS. All rights reserved.

Alliance patterns over the course of short-term dynamic psychotherapy: The shape of productive relationships.

The shape of alliance processes over the course of psychotherapy has already been studied in several process-outcome studies on very brief psychotherapy. The present study applies the shape-of-change methodology to short-term dynamic psychotherapies and complements this method with hierarchical linear modeling. A total of 50 psychotherapies of up to 40 sessions were included. Alliance was measured at the end of each session. The results indicate that a linear progression model is most adequate. Three main patterns were found: stable, linear, and quadratic growth. The linear growth pattern, along with the slope parameter, was related to treatment outcome. This study sheds additional light on alliance process research, underscores the importance of linear alliance progression for outcome, and also fosters a better understanding of its limitations.

Monitoring the effects of adult psychotherapy in routine practice in Switzerland: A feasibility trial

Background: Several studies have been published on the effects of psychotherapy in routine practice. Complementing traditional views summarised as 'dose-effect models', Stiles et al. put forward data consistent with the responsive regulation model underlining the importance of the client's active participant role in defining length of treatment. One may ask what level of change reached by a patient is considered to be the 'good enough level' (GEL) and if it is related to the duration of psychotherapy. Aims: The main objective of the present feasibility trial was to monitor the patient's session-by-session evolution using a self-report questionnaire in order to define the GEL, i.e. the number of sessions necessary for the patient to reach significant change. Method: A total of N=13 patients undergoing psychotherapy in routine practice participated in the study, completing the Outcome Questionnaire - 45.2 (OQ-45), which assesses the symptom level, interpersonal relationships and social role after every psychotherapy session. The data was analysed using multi-level analyses (HLMs). Results: High feasibility of fine-grained assessment of effects of psychotherapy in routine practice in Switzerland was shown; response rates being acceptable; however, detailed analysis of the GEL was not feasible within the short study time-frame. Conclusions: Reflections on the political context of monitoring in the specific case of routine psychiatric practice in Switzerland are discussed.

Impact of personality on termination of short-term group psychotherapy in depressed elderly outpatients

Objective Termination in group psychotherapy is an essential phase of the psychotherapeutic process, yet its clinical determinants remain largely unknown, especially in elderly patients. The aim of this study was to assess how patients' personality traits influence their way of leaving a short-term psychotherapy group as well as a larger therapeutic community program. <p>Method Personality traits were assessed with the NEO Five-Factor Inventory in 24 elderly depressed outpatients. Patients' terminations from the group as well as from the community were ranked into four classes according to their appropriateness (completeness of experience and ability to deal with feelings of separation). Results Neuroticism was not related to the quality of termination. In contrast, agreeableness and openness to experience were strongly associated with successful termination. Conscientiousness and extraversion may have a differential impact depending on the type of group (group psychotherapy versus therapeutic community). Conclusion Personality traits may be important clinical determinants of the quality of termination process in both group psychotherapy and therapeutic community settings for elderly depressed patients.