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BACKGROUND:Majority of our computed tomography-pulmonary angiography (CTPA) scans report negative findings. We hypothesized that suboptimal reliance on diagnostic algorithms contributes to apparent overuse of this test.METHODS:A retrospective review was performed on 2031 CTPA cases in a large hospital system. Investigators retrospectively calculated pretest probability (PTP). Use of CTPA was considered as inappropriate when it was ordered for patients with low PTP without checking D-dimer (DD) or following negative DD.RESULTS:Among the 2031 cases, pulmonary embolism (PE) was found in 7.4% (151 cases). About 1784 patients (88%) were considered “PE unlikely” based on Wells score. Out of those patients, 1084 cases (61%) did not have DD test prior to CTPA. In addition, 78 patients with negative DD underwent unnecessary CTPA; none of them had PE.CONCLUSIONS:The suboptimal implementation of PTP assessment tools can result in the overuse of CTPA, contributing to ineffective utilization of hospital resources, increased cost, and potential harm to patients.

Objectives Identification of racial differences in characteristics and comorbidities in patients hospitalized for COVID-19 and the impact on outcomes. Study design Retrospective observational study. Methods Data for all patients admitted to seven community hospitals in Michigan, United States with polymerase chain reaction confirmed diagnosis of COVID-19 from March 10 to April 15, 2020 was analyzed. The primary outcomes of racial disparity in inpatient mortality and intubation were analyzed using descriptive statistics and multivariate regression models. Results The study included 336 black and 408 white patients . Black patients were younger (62.9 +/- 15.0 years vs 71.8 +/- 16.4, P <.001), had a higher mean body mass index (32.4 +/- 8.6 vs 28.8 +/- 7.5, P <.001), had higher prevalence of diabetes (136/336 vs 130/408, P =.02) and presented later (6.6 +/-5.3 days after symptom onset vs. 5.4 +/- 5.4, P =.006) compared to white patients. Younger black patients had a higher prevalence of obesity (age< 65, 69.9%) than older black patients (age>65, 39.2%) and younger white patients (age<65, 55.1%). Intubation did not reach statistical significance for racial difference (black patients 61/335 vs. 54/406, P =.08). Mortality was not higher in black patients (65/335 vs. 142/406 in white patients, Odds ratio 0.61, 95% CI 0.37 to 0.99, 2 sided P =.05) in multivariate analysis, accounting for other risk factors associated with mortality. Conclusions Higher prevalence of obesity and diabetes in young black populations may be the critical factor driving disproportionate COVID-19 hospitalizations in black populations. Hospitalized black patients do not have worse outcomes compared to white patients.

Introduction. Emphysematous pyelonephritis (EPN) is an uncommon infection characterized by gas in the renal parenchyma and surrounding tissues. It is rapidly progressive, requiring appropriate therapy to salvage the infected kidney. Case Description. The case series presents 5 patients with a clinical and radiologic diagnosis of EPN. Each patient had a unique predisposing factor for developing EPN. Early goal directed therapy with intravenous fluids and antibiotics was given. This was followed by less invasive urologic interventions in an attempt to avoid nephrectomy and thereby salvage the infected kidney. All five patients were discharged in clinically stable conditions. Discussion and Conclusion. This case series provides added practice based support to available literature for managing EPN. Early goal directed medical therapy for sepsis coupled with interventional urologic procedures is a valuable alternative to circumvent an upfront emergent nephrectomy, except in cases where a fulminant infection may be present at the time of admission or develop later on in the course of the patients illness despite conservative line of therapy. It also highlights the importance of considering a diagnosis of EPN in patients with urinary infections, who have certain common predisposing factors listed in our case series.