Embargoed news from Annals of Internal Medicine

1. Algorithm May Predict Who is Likely to Die from Heart Failure in the Emergency Room
Computer Model Could Improve Clinical Decision-Making

Each year, more than one million people visit the emergency room due to heart failure. Physicians rely on clinical judgment to make decisions about hospitalization. As a result, many low-risk patients may be hospitalized unnecessarily, or some patients who are discharged may die. While models to predict short-term mortality risk exist, the models were derived using characteristics of hospitalized patients only. Researchers developed a computer-based algorithm to predict seven-day heart failure mortality rates. The researchers tested its accuracy using a population-based random sample of 12,591 patients presenting to the emergency room for heart failure between 2004 and 2007. They found the algorithm to be highly accurate at predicting who would die. This model may be useful in assessing which heart failure patients need to be hospitalized, and which can be safely treated and sent home.

2. Colorectal Cancer Screening Should Begin Early for Childhood Cancer Survivors

Childhood cancer survivors develop gastrointestinal (GI) cancers more often and at an earlier age than the general population, but research has not identified specific factors that increase the risk. Researchers surveyed 14,358 childhood cancer survivors to evaluate the risk for GI malignant neoplasms and the clinical and pathologic factors associated with their development. Patients were diagnosed with Hodgkin lymphoma, non-Hodgkin lymphoma, neuroblastoma, soft tissue sarcoma, Wilms tumor, or bone cancer before the age of 21. The researchers found that survivors were at an increased risk for GI cancer starting as early as 5.5 years after diagnosis of childhood cancer. The highest risks were seen in patients who survived Hodgkin lymphoma or Wilms tumor. Treatment with abdominal radiation and procarbazine and platinum chemotherapies was associated with the highest risk among survivors. The researchers conclude that screening childhood cancer survivors for GI cancer earlier than current guidelines recommend may be warranted, particularly among those with increased risk factors. They suggest that this population be screened every five years, beginning 10 years after radiation or by age 35, whichever is latest.

Clinical practice guidelines (CPGs) help physicians make evidence-based clinical decisions for treating and managing medical conditions. While it is expected that contributing authors are impartial experts, there is ethical debate about the influence of industry and the management of financial conflicts of interest (COI). Researchers sought to determine if an ethics framework with discussion recusal by authors with financial conflicts would affect deliberating and voting on CPGs. Thirty-four experts from 15 countries developed an international CPG on upper gastrointestinal bleeding. The experts adhered to an ethics framework where they recused themselves from scientific discussion but could vote on the CPG recommendations. The researchers found that 62 percent of the participating CPG experts had at least one financial COI. The researchers conclude that an ethics framework may help to identify and manage financial conflicts of interest, resulting in greater transparency and a balance of impartiality and expertise.