In This Issue of Archives of Internal Medicine FREE

For a 4-year period, 783 patients had malaria smears collected for suspected malaria; 145 patients had a diagnosis of malaria. In multivariate analysis, the factors predictive of malaria were a visit to sub-Saharan Africa (odds ratio [OR], 7.7; 95% confidence interval [CI], 2.8-21.3), temperature of 38.5°C or higher (OR, 6.2; 95% CI, 2.8-13.3), chills (OR, 3; 95% CI, 1.4-6.6), thrombocytopenia (OR, 16.5; 95% CI, 7.1-38.3), and abnormally high total bilirubin level (OR, 21.5; 95% CI, 6.4-72.5). However, singly or combined, these features had insufficient sensitivity (95%) and low specificity (55%) for a diagnosis of malaria. The authors conclude that all patients presenting with complaints after travel to a malaria-endemic area should be suspected of having malaria and should undergo blood microscopy.

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Using a retrospective inception cohort design and data from a linkage between the SEER cancer registry data and Medicare claims data, Menzin and colleagues evaluated outcomes among adults 65 years and older with newly diagnosed acute myeloid leukemia. The prognosis for acute myeloid leukemia was poor, with median survival estimated to be 2 months and a 2-year survival rate of 6%. Average expenditures for these patients were substantial (exceeding $40 000). A minority of patients underwent chemotherapy treatment (30%), and the use of hospice care was rare (17% of cases). Further work is needed to characterize this disease and the patient-related factors that influence treatment decisions and associated health outcomes.

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Every year, 2 to 3 per 1000 inhabitants present with suspected pulmonary embolism. The available diagnostic algorithms often consist of complex and multi-imaging tests. In this prospective study in 234 patients, Kruip et al evaluated the safety of withholding anticoagulant treatment in patients presenting with suspected pulmonary embolism, who have a low clinical probability assessment and a normal D-dimer concentration. This combination is a rapid and cost-effective method to exclude pulmonary embolism safely and is readily accepted.

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Meier et al evaluated 493 consecutive patients with suspected acute coronary syndromes to determine the diagnostic and prognostic implications of the recently changed new definition of acute myocardial infarction (AMI) per the American College of Cardiology and European Society of Cardiology. Patients with AMI were stratified into 2 groups. Group A consisted of patients diagnosed as having AMI by the World Health Organization criteria that include 2 of the following 3: ischemic symptoms, electrocardiogram suggestive of a new ST-segment elevation AMI, and an elevated creatine kinase–MB fraction (CK-MB) level. Group B included patients with only an elevated troponin level in absence of an elevated CK-MB level and thus were diagnosed as having AMI only by the new criteria. The data of Meier et al suggested that more patients with acute coronary syndromes are diagnosed as having AMI by the new criteria. Further, these additional patients diagnosed as having AMI are no less sick than those diagnosed as having AMI by old criteria and as a result have worse 6-month outcomes. Thus, the new criteria for AMI diagnosis incorporate meaningful additional risk stratification information over and above that provided by the old definition.

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