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Annals of Internal Medicine Tip Sheet
October 3, 2017

Below is information about articles being published in Annals of Internal Medicine. The information is not intended to substitute for the full article as a source of information. Annals of Internal Medicine attribution is required for all coverage.

1. Simple tool accurately predicts 30-day mortality for patients with acute heart failure in the ER


A simple tool using readily available data can accurately estimate the 30-day mortality risk for patients admitted to the emergency department with acute heart failure. Emergency department physicians may consider using this tool to inform clinical decisions. The findings are published in Annals of Internal Medicine.

Acute heart failure accounts for more than 1 million hospitalizations in the United States and Europe, and about 90 percent of patients visit the emergency department for their symptoms. Although decision making in the emergency department is critically important, emergency physicians currently do not stratify patients by risk group (low risk, intermediate risk, high risk, and very high risk). While several acute heart failure risk scores are available, a more reliable tool is needed.

Researchers for the Spanish Ministry of Health sought to predict mortality from heart failure using data from an established registry comprised of 34 Spanish emergency departments with diverse patient and facility characteristics. To create the prediction tool model, the researchers chose 13 prognostic variables and tested them against outcomes in a cohort of 4,867 consecutive emergency department patients admitted during 2009 to 2011. Then, the outcomes were tested again in an independent validation population of 3,229 patients gathered 3 years later from the same emergency departments. All of the variables chosen are readily available and familiar, except for one, and an online calculator was developed to make the tool easy for physicians to use.

The tool proved to be very accurate for predicting mortality risk, especially for the 10 percent of patients at very high risk (around 45 percent) for death at 30 days and in the 40 percent of patients at low risk (less than 2 percent). Identification of both groups has important management implications.

2. More screening is not always better

Experts go ‘Beyond the Guidelines’ to discuss screening for carotid artery stenosis in clinical context


Should a 74-year-old man with risk factors for cardiovascular disease be screened for carotid artery stenosis (CAS) upon request? A vascular surgeon and a primary care physician, both from Beth Israel Deaconess Medical Center (BIDMC), weigh this question in a multicomponent educational article being published in Annals of Internal Medicine.

Stroke is a leading cause of death and major morbidity in the United States. The majority of strokes are ischemic and 10 percent of all ischemic strokes are due to CAS. However, current guidelines from the U.S. Preventive Services Task Force (USPSTF) recommend against screening in asymptomatic adults based on 3 large randomized controlled trials showing that the potential harms could outweigh the benefits. Harms associated with screening included need for angiography for confirmation after abnormal carotid ultrasonography. Treatment to reduce plaque found on screening was also associated with harms. In addition to stroke or death, harms included cranial nerve injury, pulmonary embolism, pneumonia, myocardial infarction, and local hematoma.

Despite the evidence, individual patients may seek advice from their physician regarding screening. Two prominent medical experts discuss whether or not to screen for CAS in a 74-year-old individual who, at first glance, appears to be a reasonable candidate for further testing, due to his age and other risk factors.

Vascular surgeon Marc Schermerhorn, MD, argues that screening only has value when the prevalence in a given population exceeds 20 percent. The patient’s risk for significant CAS is less than 1 percent, making screening unadvisable. Primary care physician Kenneth Mukamal, MD, agrees with Dr. Schermerhorn and also notes that the positive predictive value of screening is poor, but aggressive medical therapy can reduce stroke risk. Both physicians recommend that the patient consider enrolling in a clinical trial, such as the ongoing CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) trial, if he is contemplating screening.

All ‘Beyond the Guidelines’ papers are based on the Department of Medicine Grand Rounds at BIDMC in Boston and include print, video, and educational components. A list of topics is available at

3. Delayed reaction to tattoo pigment may mimic lymphoma


Swollen lymph nodes resulting from a reaction to tattoo pigment may mimic the clinical and radiological features of lymphoma. A case study from Royal Prince Alfred Hospital in Sydney, Australia is published in Annals of Internal Medicine.

Decorative tattooing is associated with acute complications, such as pain, infection, and hypersensitivity. Delayed reactions also occur (one case reportedly occurred 30 years after tattooing), including regional lymphoadenopathy (enlarged lymph nodes) that may masquerade as malignant disease.

Researchers describe the case of a 30-year-old woman who presented to their clinic reporting a 2-week history of bilateral axillary lumps. Her symptoms mimicked lymphoma, but clinical tests showed that the lumps were benign. After a thorough examination, her physicians concluded that her symptoms were caused by a reaction to tattooing that had been done 15 years prior. According to the authors, this case highlights the importance of a careful tattoo history and physical examination for cases of lymphadenopathy.

Also in this issue:

Screening for Colorectal Cancer With Fecal Immunochemical Testing With and Without Postpolypectomy Surveillance Colonoscopy: A Cost-Effectiveness Analysis

Marjolein J.E. Greuter, PhD; Clasine M. de Klerk, MD; Gerrit A. Meijer, MD, PhD; Evelien Dekker, MD, PhD; and Veerie M.H. Coupé, PhD
Original Research


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