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Sanchez O, Roy PM, Gaboreau Y, Schmidt J, Moustafa F, Benmaziane A, Élias A, Espitia O, Sevestre MA, Couturaud F, Mahé I. [Translation into French and republication of: "Home treatment for patients with cancer-associated venous thromboembolism"]. Rev Med Interne 2024; 45:226-238. [PMID: 38632029 DOI: 10.1016/j.revmed.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 04/19/2024]
Abstract
Patients hospitalised with acute venous thromboembolism (VTE), and notably patients with pulmonary embolism, often remain in hospital for extended periods due to the perceived risk of complications. However, several studies have shown that home treatment of selected patients is feasible and safe, with a low incidence of adverse events. This may offer clear benefits for patients' quality of life, hospital planning and cost to the health service. Nonetheless, there is a need for a VTE risk-stratification tool specifically addressing prognosis in patients with cancer. This may aid in the selection of low-risk patients with cancer and VTE who are suitable for outpatient treatment. Although several prognostic scores have been proposed, we suggest using a pragmatic clinical decision-making tool such as the Hestia criteria for selecting patients for home care in everyday clinical practice. Once patients have been discharged, it is mandatory to monitor patients regularly (we suggest after 3 days, 10 days, 1 month and 3 months, or more frequently if needed) with the involvement of a multidisciplinary team, so that appropriate and timely remedial action can be taken in case of warning signs of complications. If patients are selected carefully and monitored effectively, many patients who experience acute VTE can be cared for safely at home.
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Affiliation(s)
- Olivier Sanchez
- Service de pneumologie et de soins intensifs, hôpital européen Georges-Pompidou, AP-HP, Paris, France; Université Paris Cité, Inserm UMR S1140, Innovations thérapeutiques en hémostase, Paris, France; F-Crin INNOVTE network, Saint-Étienne, France.
| | - Pierre-Marie Roy
- Service de médecine d'urgence, CHU d'Angers, université d'Angers, UMR MitoVasc CNRS 6015-Inserm 1083, équipe Carme, Angers, France; F-Crin INNOVTE network, Saint-Étienne, France
| | - Yoann Gaboreau
- Département de médecine générale, faculté de médecine, Techniques de l'ingénierie médicale et de la complexité (Timc), université Grenoble Alpes, Grenoble, France
| | - Jeannot Schmidt
- Service d'urgence, CHU de Clermont-Ferrand, Lapsco-UMR UBP-CNRS 6024, université Clermont Auvergne, Clermont-Ferrand, France; F-Crin INNOVTE network, Saint-Étienne, France
| | - Farès Moustafa
- Inrae, UNH, département urgence, hôpital de Clermont-Ferrand, université Clermont Auvergne, Clermont-Ferrand, France; F-Crin INNOVTE network, Saint-Étienne, France
| | | | - Antoine Élias
- Département de cardiologie et de médecine vasculaire, délégation Recherche clinique et innovation, centre hospitalier intercommunal de Toulon La Seyne-sur-Mer, Toulon, France; F-Crin INNOVTE network, Saint-Étienne, France
| | - Olivier Espitia
- Service de médecine interne et vasculaire, Institut du thorax, Nantes université, CHU de Nantes, Inserm UMR 1087 - CNRS UMR 6291, Team III Vascular & pulmonary diseases, Nantes, France
| | - Marie-Antoinette Sevestre
- Service de médecine vasculaire, ÉA Chimère 7516, CHU d'Amiens-Picardie, Amiens, France; F-Crin INNOVTE network, Saint-Étienne, France
| | - Francis Couturaud
- Département de médecine interne, médecine vasculaire et pneumologie, CHU de Brest, Inserm U1304 - Getbo, université de Brest, Brest, France; F-Crin INNOVTE network, Saint-Étienne, France
| | - Isabelle Mahé
- Université Paris Cité, Inserm UMR S1140, Innovations thérapeutiques en hémostase, Paris, France; Service de médecine interne, hôpital Louis-Mourier, AP-HP, Colombes, France; F-Crin INNOVTE network, Saint-Étienne, France
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Douillet D, Penaloza A, Viglino D, Banihachemi JJ, Abboodi A, Helderlé M, Montassier E, Balen F, Brice C, Laribi S, Duchenoy T, Vives P, Soulat L, Marjanovic N, Moumneh T, Savary D, Riou J, Roy PM. Targeted prophylactic anticoagulation based on the TRiP(cast) score in patients with lower limb immobilisation: a multicentre, stepped wedge, randomised implementation trial. Lancet 2024; 403:1051-1060. [PMID: 38368901 DOI: 10.1016/s0140-6736(23)02369-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/14/2023] [Accepted: 10/20/2023] [Indexed: 02/20/2024]
Abstract
BACKGROUND Prophylactic anticoagulation in emergency department patients with lower limb trauma requiring immobilisation is controversial. The Thrombosis Risk Prediction for Patients with Cast Immobilisation-TRiP(cast)-score could identify a large subgroup of patients at low risk of venous thromboembolism for whom prophylactic anticoagulation can be safely withheld. We aimed to prospectively assess the safety of withholding anticoagulation for patients with lower limb trauma at low risk of venous thromboembolism, defined by a TRiP(cast) score of less than 7. METHODS CASTING was a stepped-wedge, multicentre, cluster-randomised trial with blinded outcome assessment. 15 emergency departments in France and Belgium were selected and randomly assigned staggered start dates for switching from the control phase (ie, anticoagulation prescription according to the physician's usual practice) to the intervention phase (ie, targeted anticoagulation according to TRiP(cast) score: no prescription if score <7 and anticoagulation if score was ≥7). Patients were included if they presented to a participating emergency department with lower limb trauma requiring immobilisation for at least 7 days and were aged 18 years or older. The primary outcome was the 3-month cumulative rate of symptomatic venous thromboembolism during the intervention phase in patients with a TRiP(cast) score of less than 7. The targeted strategy was considered safe if this rate was less than 1% with an upper 95% CI of less than 2%. The primary analysis was performed in the intention-to-treat population. This study is registered at ClinicalTrials.gov (NCT04064489). FINDINGS Between June 16, 2020, and Sept 15, 2021, 15 clusters and 2120 patients were included. Of the 1505 patients analysed in the intervention phase, 1159 (77·0%) had a TRiP(cast) score of less than 7 and did not receive anticoagulant treatment. The symptomatic venous thromboembolism rate was 0·7% (95% CI 0·3-1·4, n=8/1159). There was no difference between the control and the intervention phases in the cumulative rate of symptomatic venous thromboembolism or in bleeding rates. INTERPRETATION Patients with a TRiP(cast) score of less than 7 who are not receiving anticoagulation have a very low risk of venous thromboembolism. A large proportion of patients with lower limb trauma and immobilisation could safely avoid thromboprophylaxis. FUNDING French Ministry of Health.
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Affiliation(s)
- Delphine Douillet
- Emergency Department, Health Faculty, Angers University Hospital, Angers, France; UMR MitoVasc CNRS 6015 - INSERM 1083, Equipe CARME, UNIV Angers, Angers, France; F-CRIN INNOVTE Network, Saint-Etienne, France.
| | - Andrea Penaloza
- F-CRIN INNOVTE Network, Saint-Etienne, France; Emergency Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Damien Viglino
- Emergency Department, University Hospital of Grenoble Alpes, University Grenoble-Alpes, Grenoble, France; HP2 Laboratory, Grenoble Alpes University, INSERM U1300, Grenoble, France
| | - Jean-Jacques Banihachemi
- Department of Trauma and Musculo-Skeletal Emergency, University Hospital and Medical Centre of Grenoble-Alpes Hospital South, Grenoble, France
| | - Anmar Abboodi
- Emergency Department, Cholet Hospital, Cholet, France
| | | | - Emmanuel Montassier
- Emergency Department, Nantes University Hospital, Nantes, France; MiHAR Laboratary, EE1701, University of Nantes, Nantes, France
| | - Fréderic Balen
- Department of Emergency Medicine, Toulouse University Hospital, Toulouse, France
| | - Christian Brice
- Emergency Department, Centre Hospitalier de Saint-Brieuc, Saint-Brieuc, France
| | - Saïd Laribi
- Emergency Department, Tours University Hospital, Tours, France
| | | | | | - Louis Soulat
- Emergency Department, Rennes University Hospital, Rennes, France
| | | | - Thomas Moumneh
- Emergency Department, Health Faculty, Angers University Hospital, Angers, France; F-CRIN INNOVTE Network, Saint-Etienne, France
| | - Dominique Savary
- Emergency Department, Health Faculty, Angers University Hospital, Angers, France
| | - Jérémie Riou
- Methodology and Biostatistics Department, Delegation to Clinical Research and Innovation, Angers University Hospital, Angers, France
| | - Pierre-Marie Roy
- Emergency Department, Health Faculty, Angers University Hospital, Angers, France; UMR MitoVasc CNRS 6015 - INSERM 1083, Equipe CARME, UNIV Angers, Angers, France; F-CRIN INNOVTE Network, Saint-Etienne, France
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Chaibi S, Roy PM, Guénégou AA, Tran Y, Hugli O, Penaloza A, Couturaud F, Tromeur C, Szwebel TA, Pernod G, Elias A, Ghuysen A, Benhamou Y, Falvo N, Juchet H, Nijkeuter M, Mairuhu R, Faber LM, Mahé I, Montaclair K, Planquette B, Jimenez D, Huisman MV, Klok FA, Sanchez O. Outpatient management of cancer-associated pulmonary embolism: A post-hoc analysis from the HOME-PE trial. Thromb Res 2024; 235:79-87. [PMID: 38308882 DOI: 10.1016/j.thromres.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 01/15/2024] [Accepted: 01/18/2024] [Indexed: 02/05/2024]
Abstract
INTRODUCTION Cancer-related pulmonary embolism (PE) is associated with poor prognosis. Some decision rules identifying patients eligible for home treatment categorize cancer patients at high risk of complications, precluding home treatment. We sought to assess the effectiveness and the safety of outpatient management of patients with low-risk cancer-associated PE. METHODS In the HOME-PE trial, hemodynamically stable patients with symptomatic PE were randomized to either triaging with Hestia criteria or sPESI score. We analyzed 3 groups of low-risk PE patients: 47 with active cancer treated at home (group 1), 691 without active cancer treated at home (group 2), and 33 with active cancer as the only sPESI criterion qualifying them for hospitalization (group 3). The main outcome was the composite of recurrent venous thromboembolism, major bleeding, and all-cause death within 30 days after randomization. RESULTS Patients treated at home had composite outcome rates of 4.3 % (2/47) for those with cancer vs. 1.0 % (7/691) for those without (odds ratio (OR) 4.98, 95%CI 1.15-21.49). Patients with cancer had rates of complications of 4.3 % when treated at home vs. 3.0 % (1/33) when hospitalized (OR 1.19, 95%CI 0.15-9.47). In multivariable analysis, active cancer was associated with an increased risk of complications for patients treated at home (OR 7.95; 95%CI 1.48-42.82). For patients with active cancer, home treatment was not associated with the primary outcome (OR 1.19, 95%CI 0.15-9.74). CONCLUSIONS Among patients treated at home, active cancer was a risk factor for complications, but among patients with active cancer, home treatment was not associated with adverse outcomes.
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Affiliation(s)
- Sérine Chaibi
- Université Paris Cité, Paris, France; Department of Pneumology and Intensive Care, Hôpital Européen Georges Pompidou, AP-HP, Paris F-75908, France
| | - Pierre-Marie Roy
- Emergency Department, CHU Angers, Angers F-49000, France; Univ. Angers, INSERM, CNRS, MITOVASC, Equipe CARME, SFR ICAT, Angers, France; F-CRIN, INNOVTE, Saint-Etienne, France
| | - Armelle Arnoux Guénégou
- Université Paris Cité, AP-HP, Hôpital Européen Georges Pompidou, Clinical research unit, Clinical Investigation Center 1418 Clinical Epidemiology, INSERM, INRIA, HeKA, Paris, France
| | - Yohann Tran
- Université Paris Cité, AP-HP, Hôpital Européen Georges Pompidou, Clinical research unit, Clinical Investigation Center 1418 Clinical Epidemiology, INSERM, Paris, France
| | - Olivier Hugli
- Emergency Department, University Hospital of Lausanne and Lausanne University, Lausanne, Switzerland
| | - Andréa Penaloza
- Emergency Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium; UCLouvain, Brussels, Belgium
| | - Francis Couturaud
- F-CRIN, INNOVTE, Saint-Etienne, France; Department of Internal Medicine and Chest Disease, CHU Brest, Brest, France; INSERM U1304-GETBO, CIC-INSERM1412, Univ-Brest, F20609 Brest, France
| | - Cécile Tromeur
- F-CRIN, INNOVTE, Saint-Etienne, France; Department of Internal Medicine and Chest Disease, CHU Brest, Brest, France; INSERM U1304-GETBO, CIC-INSERM1412, Univ-Brest, F20609 Brest, France
| | - Tali-Anne Szwebel
- Department of Internal Medicine, Cochin Hospital, APHP, Paris, France
| | - Gilles Pernod
- F-CRIN, INNOVTE, Saint-Etienne, France; Department of Vascular Medicine, CHU Grenoble Alpes, Grenoble, France; University Grenoble Alpes, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble, France
| | - Antoine Elias
- F-CRIN, INNOVTE, Saint-Etienne, France; Department of Cardiology and Vascular Medicine, Sainte Musse Hospital, Centre Hospitalier Intercommunal Toulon La Seyne sur Mer, Toulon, France
| | - Alexandre Ghuysen
- Emergency Department, Sart Tilman University Hospital, Liège, Belgium
| | - Ygal Benhamou
- F-CRIN, INNOVTE, Saint-Etienne, France; Department of Internal Medicine, CHU Charles Nicolle, Rouen, France; Normandie University, UNIROUEN, INSERM U1096 EnVI, Rouen, France
| | - Nicolas Falvo
- F-CRIN, INNOVTE, Saint-Etienne, France; Vascular Medicine Department, CHU Dijon, Dijon, France
| | - Henry Juchet
- Emergency Department, CHU Toulouse, Toulouse, France
| | - Mathilde Nijkeuter
- Department of emergency medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ronne Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands
| | - Laura M Faber
- Department of Internal Medicine, Rode Kruis Hospital, Beverwijk, DTN, the Netherlands
| | - Isabelle Mahé
- Université Paris Cité, Paris, France; F-CRIN, INNOVTE, Saint-Etienne, France; Department of Internal Medicine, Louis Mourier Hospital, AP-HP, Colombes, France; Inserm UMR_S1140 Innovations Thérapeutiques en Hémostase, Paris, France
| | - Karine Montaclair
- F-CRIN, INNOVTE, Saint-Etienne, France; Department of Cardiology, CH Le Mans, Le Mans, France
| | - Benjamin Planquette
- Université Paris Cité, Paris, France; Department of Pneumology and Intensive Care, Hôpital Européen Georges Pompidou, AP-HP, Paris F-75908, France; F-CRIN, INNOVTE, Saint-Etienne, France; Inserm UMR_S1140 Innovations Thérapeutiques en Hémostase, Paris, France
| | - David Jimenez
- Respiratory Department and Medicine Department, Ramon y Cajal Hospital (IRYCIS) and Alcala University, CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Federikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Olivier Sanchez
- Université Paris Cité, Paris, France; Department of Pneumology and Intensive Care, Hôpital Européen Georges Pompidou, AP-HP, Paris F-75908, France; F-CRIN, INNOVTE, Saint-Etienne, France; Inserm UMR_S1140 Innovations Thérapeutiques en Hémostase, Paris, France.
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Douillet D, Plard D, Morin F, Courjault Y, Gaultier G, Lerolle N, Templier F, Roy PM, Savary D. Overcrowding in the Dispatching Centre During the COVID-19 Crisis: Are Medical Students a Resource? Disaster Med Public Health Prep 2024; 18:e38. [PMID: 38415406 DOI: 10.1017/dmp.2024.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
INTRODUCTION In February, the emergence of COronaVIrus Disease 2019 (COVID - 19) in France made it necessary to rapidly adapt emergency and SAMU services in order to take care of many infected patients. To respond to the increase in the number of calls in the dispatch centers, reinforcements were necessary on the fronts of the Medical Regulation Assistants (ARM). The aim of this study was to assess the relevance of medical students' responses to first calls exclusively concerning COVID-19. METHODS This prospective, observational cohort study was carried out at the University Hospital Centre (CHU) in Angers. Twenty medical students mostly in the 5th year were voluntarily enrolled in the first line COVID-19 call taker team. Calls on the 1st, 3rd, and 5th starting day for each medical student, and randomly selected calls from the experienced first-line call taker were listened to by a medical expert to assess the adequate level of prioritization and orientation (emergency physician or general practitioner). The percentage of agreement between the expert, students, and experienced first-line call handlers were assessed. All participants gave their free consent to participate. The study was approved by the Ethics Committee of Angers (N° 2020-48). RESULTS From March 18 to April 23, 2020, 302 calls from medical students (n = 20 students) and 40 calls from experienced first-line call handlers were analyzed. The average prioritization agreement rate between the expert and students was 76.16% (95% Confidence Interval: 71.04 to 80.62%) (n = 230/302) compared to 87.50% (95% CI: 73.9 to 94.5%) (n = 45/50) for the experienced first-line call handlers (P = 0.15). Medical students took more time per call with an absolute difference of 2 minutes 16 seconds (P < 0.001). CONCLUSION The lessons to be observed from this COVID-19 crisis are that in the early days of increasing calls heralding a strain on the healthcare system, support by medical students must be considered.
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Affiliation(s)
- Delphine Douillet
- Emergency Department, Angers University Hospital, University of Angers, Angers, France
- UMR MitoVasc, Health Faculty, University of Angers, Angers, France
| | - Delphine Plard
- Emergency Department, Angers University Hospital, University of Angers, Angers, France
| | - François Morin
- Emergency Department, Angers University Hospital, University of Angers, Angers, France
| | - Yannick Courjault
- Emergency Department, Angers University Hospital, University of Angers, Angers, France
| | - Gwladys Gaultier
- Emergency Department, Angers University Hospital, University of Angers, Angers, France
| | - Nicolas Lerolle
- Medical Intensive Care Unit, CHU Angers, Angers University Hospital, Angers, France
| | - François Templier
- Emergency Department, Angers University Hospital, University of Angers, Angers, France
| | - Pierre-Marie Roy
- Emergency Department, Angers University Hospital, University of Angers, Angers, France
- UMR MitoVasc, Health Faculty, University of Angers, Angers, France
| | - Dominique Savary
- Emergency Department, Angers University Hospital, University of Angers, Angers, France
- EHESP, Irset, Inserm, University of Rennes, Rennes, France
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Gaugler JO, Righini M, Robert-Ebadi H, Sanchez O, Roy PM, Verschuren F, Miranda S, Delluc A, Le Gal G, Tritschler T. Obesity as a Predictor for Pulmonary Embolism and Performance of the Age-Adjusted D-Dimer Strategy in Obese Patients with Suspected Pulmonary Embolism. Thromb Haemost 2024; 124:49-57. [PMID: 37308131 DOI: 10.1055/s-0043-57018] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Obesity is a risk factor for venous thromboembolism, but studies evaluating its association with pulmonary embolism (PE) in patients with suspected PE are lacking. OBJECTIVES To evaluate whether body mass index (BMI) and obesity (i.e., BMI ≥30 kg/m2) are associated with confirmed PE in patients with suspected PE and to assess the efficiency and safety of the age-adjusted D-dimer strategy in obese patients. METHODS We conducted a secondary analysis of a multinational, prospective study, in which patients with suspected PE were managed according to the age-adjusted D-dimer strategy and followed for 3 months. Outcomes were objectively confirmed PE at initial presentation, and efficiency and failure rate of the diagnostic strategy. Associations between BMI and obesity, and PE were examined using a log-binomial model that was adjusted for clinical probability and hypoxia. RESULTS We included 1,593 patients (median age: 59 years; 56% women; 22% obese). BMI and obesity were not associated with confirmed PE. The use of the age-adjusted instead of the conventional D-dimer cut-off increased the proportion of obese patients in whom PE was considered ruled out without imaging from 28 to 38%. The 3-month failure rate in obese patients who were left untreated based on a negative age-adjusted D-dimer cut-off test was 0.0% (95% confidence interval: 0.0-2.9%). CONCLUSION BMI on a continuous linear scale and obesity were not predictors of confirmed PE among patients presenting with a clinical suspicion of PE. The age-adjusted D-dimer strategy appeared safe in ruling out PE in obese patients with suspected PE.
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Affiliation(s)
- Jan O Gaugler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - Olivier Sanchez
- Université Paris Cité, Paris, France
- Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
- INSERM UMR S 1140, Innovative Therapies in Hemostasis, Paris, France
| | - Pierre-Marie Roy
- Department of Emergency Medicine, University Hospital of Angers, Angers, France
- UMR MitoVasc CNRS 6015 - INSERM 1083, Health Faculty, Angers, France
| | - Franck Verschuren
- Emergency Department, Saint-Luc University Hospital, IREC Institute, Université Catholique de Louvain, Brussels, Belgium
| | - Sebastien Miranda
- Department of Internal Medicine, Rouen University Hospital, Normandie University, UNIROUEN, INSERM U1096, Rouen, France
| | - Aurélien Delluc
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
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Sanchez O, Roy PM, Gaboreau Y, Schmidt J, Moustafa F, Benmaziane A, Elias A, Espitia O, Sevestre MA, Couturaud F, Mahé I. Home treatment for patients with cancer-associated venous thromboembolism. Arch Cardiovasc Dis 2024; 117:16-28. [PMID: 38092577 DOI: 10.1016/j.acvd.2023.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 12/27/2023]
Abstract
Patients hospitalised with acute venous thromboembolism (VTE), and notably patients with pulmonary embolism, often remain in hospital for extended periods due to the perceived risk of complications. However, several studies have shown that home treatment of selected patients is feasible and safe, with a low incidence of adverse events. This may offer clear benefits for patients' quality of life, hospital planning and cost to the health service. Nonetheless, there is a need for a VTE risk-stratification tool specifically addressing prognosis in patients with cancer. This may aid in the selection of low-risk patients with cancer and VTE who are suitable for outpatient treatment. Although several prognostic scores have been proposed, we suggest using a pragmatic clinical decision-making tool such as the Hestia criteria for selecting patients for home care in everyday clinical practice. Once patients have been discharged, it is mandatory to monitor patients regularly (we suggest after 3 days, 10 days, 1 month and 3 months, or more frequently if needed) with the involvement of a multidisciplinary team, so that appropriate and timely remedial action can be taken in case of warning signs of complications. If patients are selected carefully and monitored effectively, many patients who experience acute VTE can be cared for safely at home.
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Affiliation(s)
- Olivier Sanchez
- Service de pneumologie et de soins intensifs, hôpital européen Georges-Pompidou, AP-HP, Paris, France; Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; F-CRIN INNOVTE network, Saint-Etienne, France.
| | - Pierre-Marie Roy
- Service de médecine d'urgences, CHU Angers, Université d'Angers, UMR MitoVasc CNRS 6015 - Inserm 1083, équipe CARME, Angers, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Yoann Gaboreau
- Département de médecine générale, faculté de médicine, techniques de l'ingénierie médicale et de la complexité (TIMC), université Grenoble-Alpes, Grenoble, France
| | - Jeannot Schmidt
- Service d'urgence, CHU de Clermont-Ferrand, LAPSCO-UMR UBP-CNRS 6024, Université Clermont Auvergne, Clermont-Ferrand, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Farès Moustafa
- Inrae, UNH, département urgence, hôpital de Clermont Ferrand, université Clermont Auvergne, Clermont-Ferrand, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | | | - Antoine Elias
- Département de cardiologie et de médecine vasculaire, délégation recherche clinique et innovation, centre hospitalier intercommunal Toulon La Seyne-sur-Mer, Toulon, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Olivier Espitia
- Service de médecine interne et vasculaire, institut du thorax, Nantes université, CHU de Nantes, Inserm UMR 1087 -CNRS UMR 6291, Team III Vascular & Pulmonary diseases, Nantes, France
| | - Marie-Antoinette Sevestre
- Service de médecine vasculaire, EA Chimère 7516 CHU d'Amiens-Picardie, Amiens, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Francis Couturaud
- Département de médecine interne, médecine vasculaire et pneumologie, CHU de Brest, Inserm U1304 -GETBO, université de Brest, Brest, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Isabelle Mahé
- Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; Service de médecine interne, hôpital Louis-Mourier, AP-HP, Colombes, France; F-CRIN INNOVTE network, Saint-Etienne, France
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Chiang P, Robert-Ebadi H, Perrier A, Roy PM, Sanchez O, Righini M, Le Gal G. Pulmonary embolism risk stratification: external validation of the 4-level Clinical Pretest Probability Score (4PEPS). Res Pract Thromb Haemost 2024; 8:102348. [PMID: 38444614 PMCID: PMC10912690 DOI: 10.1016/j.rpth.2024.102348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 12/30/2023] [Accepted: 01/30/2024] [Indexed: 03/07/2024] Open
Abstract
Background The 4-level clinical pretest probability score (4PEPS) was recently introduced as a clinical decision rule for the diagnosis of pulmonary embolism (PE). Based on the score, patients are classified into clinical pretest probability categories (c-PTP). The "very low" category aims at excluding PE without further testing; "low" and "moderate" categories require D-dimer testing with specific thresholds, while patients with a "high" pretest directly proceed to imaging. Objectives To provide further external validation of the 4PEPS model. Methods The 4PEPS was applied to a previously collected prospective database of 756 patients with clinically suspected PE enrolled from European emergency departments in 2002 to 2003. The safety threshold for the failure rate in our study was calculated at 1.95% based on a 26% prevalence of PE in our study, as per the International Society on Thrombosis and Haemostasis Scientific and Standardization Committee guidance. Results Patients were classified as follows: 90 (12%) in the very low c-PTP group, of whom 5 (5.6%; 95% CI, 2.4%-12.4%) had PE; 363 (49%) in the low c-PTP group, of whom 34 had PE (9.4%); 246 (34%) in the moderate c-PTP group, of whom 124 (50%) had PE; and 35 (5%) in the high c-PTP group of whom 30 (86%) had PE. Overall, the failure rate of the 4PEPS was 9/734 (1.2%; 95% CI, 0.59%-2.23%) Overall, 9 out of 734 patients (1.2%; 95% CI, 0.59%-2.23%) were diagnosed with PE despite a negative 4PEPS rule; 5 (5.6%) from the very low c-PTP group, 3 (1.4%) in the low c-PTP group, and 1 (3.2%) in the moderate c-PTP group. Conclusion We provide external validation data of the 4PEPS. In this high-prevalence cohort (26% prevalence), PE prevalence in the very low-risk group was higher than expected. A prospective validation study is needed before implementing the 4PEPS model in routine clinical practice.
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Affiliation(s)
- Philip Chiang
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Arnaud Perrier
- Department of Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Pierre-Marie Roy
- Department of Emergency Medicine, University Hospital of Angers, Angers, France
| | - Olivier Sanchez
- Department of Respiratory Disease, Hôpital Européen Georges Pompidou, Hôpital de l'Assistance publique - Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
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Teissandier D, Philippon AL, Bannelier H, Roy PM, Penaloza A, Jiménez S, Freund Y, Roussel M, Catoire P. Pulmonary embolism rule-out decision-making tools for patients aged 35 years or younger in hospital emergency departments: a post-hoc analysis of performance in 3 prospective cohorts. Emergencias 2023; 35:432-436. [PMID: 38116967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
OBJECTIVES To assess the performance of the Pulmonary Embolism Rule-out Criteria (PERC) and the age-modified PERC-35 tool in hospital emergency departments (EDs) for evaluating patients aged 35 years or younger. A secondary aim was to assess other decision-making criteria. MATERIAL AND METHODS Post-hoc analysis of 3 European cohort studies. We included data for patients aged 35 years or younger suspected of PE who were followed for 3 months. The safety and efficacy of applying the PERC and PERC-35 were assessed with the diagnostic error rate (failure to detect PE) and the proportion of patients in whom a diagnosis of PE was ruled out. We also assessed the safety and efficacy of applying the YEARS and PEGeD criteria. RESULTS Data for 1235 patients aged 35 years or younger were analyzed. Twenty-two (1.8%; 95% CI, 1.2%-2.7%) PE cases were diagnosed at 3 months. Six (1.0%; 95% CI, 0.5%-2.2%) and 5 (0.9%; 95% CI, 0.4%-2.1%) PE cases were not diagnosed by the PERC and PERC-35 tools, respectively. These tools allowed PE to be ruled out in 591 (48.2%; 95% CI, 45.4%-51.0%) and 554 (46.2%; 95% CI, 43.4%-49.0%) cases, respectively. The error rates of the YEARS and PEGeD criteria, respectively, were 0.4% (95% CI, 0.1%-1.1%) and 0.5% (95% CI, 0.2%-1.2%); their efficacy was similar. CONCLUSION The safety and efficacy profiles of the PERC and PERC-35 algorithms were similar in patients aged 35 years or younger. However, the large confidence intervals we report do not allow us to confirm the safety of using the tools in patients in this age group.
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Affiliation(s)
- Dorian Teissandier
- Servicio de Urgencias, Hôpital Pitié-Salpêtrière, Sorbonne Université, París, Francia
| | - Anne-Laure Philippon
- Servicio de Urgencias, Hôpital Pitié-Salpêtrière, Sorbonne Université, París, Francia. FHU IMPEC Improving Emergency Care, UMR 1166, IHU ICAN, Sorbonne Université, París, Francia
| | - Héloise Bannelier
- FHU IMPEC Improving Emergency Care, UMR 1166, IHU ICAN, Sorbonne Université, París, Francia
| | - Pierre-Marie Roy
- Servicio de Urgencias, Centre Hospitalier Universitaire Angers, Institut Mitovasc, Université d'Angers, Angers, Francia
| | - Andrea Penaloza
- Servicio de Urgencias, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Brussels, Bélgica
| | - Sònia Jiménez
- Servicio de Urgencias, Hospital Clínic, IDIBAPS, Barcelona, Universidad de Barcelona, Barcelona, España
| | - Yonathan Freund
- Servicio de Urgencias, Hôpital Pitié-Salpêtrière, Sorbonne Université, París, Francia. FHU IMPEC Improving Emergency Care, UMR 1166, IHU ICAN, Sorbonne Université, París, Francia
| | - Melanie Roussel
- Servicio de Urgencias, Centre Hospitalier Universitaire de Rouen, Université de Normandie UNIROUEN, Rouen, Francia
| | - Pierre Catoire
- Servicio de Urgencias, Hôpital Pitié-Salpêtrière, Sorbonne Université, París, Francia. FHU IMPEC Improving Emergency Care, UMR 1166, IHU ICAN, Sorbonne Université, París, Francia
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Grand F, Blanc-Jouvan F, Delassasseigne C, Galinat H, Roy PM, Talon L, Toussaint-Hacquard M, Macchi L. [Point-of-care testing for D-dimer in the exclusion of venous thromboembolism: a critical analysis]. Ann Biol Clin (Paris) 2023; 81:abc.2023.1839. [PMID: 38018826 DOI: 10.1684/abc.2023.1839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
Point-of-care testing (POCT) for D-dimer is an alternative to -laboratory testing for the exclusion of venous thromboembolism (VTE). This critical review by the "CEC et biologie délocalisée" working group of the "Société Française de Thrombose et d'Hémostase" (French Society of -Thrombosis and Haemostasis) aims to present the characteristics of six POCT D-dimer assays available in France in 2023. The article highlights the need to define VTE -exclusion thresholds specific to each technique and validated by clinical studies. There is insufficient data to validate the use of cut off suggested by manufacturers, and age-adjusted thresholds. The article discusses the role of laboratories in justifying and prescribing POCT D-dimer, according to objective criteria, such as the availability and turnaround time of classical laboratory tests. They should also encourage rational prescribing, limited to patients with low risk of venous thromboembolism, following an assessment of clinical probability according to national and international guidelines.
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Affiliation(s)
- François Grand
- Laboratoire d'Hématologie Biologique, Université de Poitiers, CHU de Poitiers, 2 rue de la Milétrie, 86000 Poitiers, France
| | - Florence Blanc-Jouvan
- Laboratoire d'hématologie, Centre Hospitalier Annecy Genevois, 1 avenue de l'Hôpital, 74370 Epagny Metz-Tessy, France
| | - Céline Delassasseigne
- Laboratoire d'hématologie, CHU de Bordeaux, Hôpital Haut-Lévêque, Avenue de Magellan, 33604 Pessac Cedex, France
| | - Hubert Galinat
- Laboratoire d'hématologie, CHU Brest, Boulevard Tanguy Prigent, 29200 Brest, France
| | - Pierre-Marie Roy
- Département de Médicine d'Urgence, UNIV Angers, UMR MitoVasc CNRS 6015 - INSERM 1083, Equipe CARME, CHU d'Angers, 4 rue Larrey, 49000 Angers, France
| | - Laurie Talon
- Service d'hématologie biologique, CHU de Clermont-Ferrand, 1 place Lucie-Aubrac, 63003 Clermont-Ferrand, France
| | | | - Laurent Macchi
- Laboratoire d'Hématologie Biologique, Université de Poitiers, CHU de Poitiers, 2 rue de la Milétrie, 86000 Poitiers, France
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Rambaud G, Mai V, Motreff C, Sanchez O, Roy PM, Auffret Y, Le Mao R, Gagnadoux F, Paleiron N, Schmidt J, Pastre J, Nonent M, Tromeur C, Salaun PY, Mismetti P, Girard P, Lacut K, Lemarié CA, Meyer G, Leroyer C, Le Gal G, Bertoletti L, Couturaud F. Pulmonary embolism diagnostic strategies in patients with COPD exacerbation: Post-hoc analysis of the PEP trial. Thromb Res 2023; 231:58-64. [PMID: 37806116 DOI: 10.1016/j.thromres.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/27/2023] [Accepted: 09/25/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND The prevalence of pulmonary embolism (PE) is approximately 11-17 % in patients with an acute exacerbation of chronic obstructive pulmonary disease (AE-COPD). The optimal diagnostic strategy for PE in these patients remains undetermined. AIMS To evaluate the safety and efficacy of standard (revised Geneva and Wells PE scores combined with fixed D-dimer cut-off) and computed tomography pulmonary angiogram (CTPA)-sparing diagnostic strategies (ADJUST-PE, YEARS, PEGeD, 4PEPS) in patients with AE-COPD. METHOD Post-hoc analyses of data from the multicenter prospective PEP study were performed. The primary outcome was the diagnostic failure rate of venous thromboembolism (VTE) during the entire study period. Secondary outcomes included diagnostic failure rate of PE and deep venous thrombosis (DVT), respectively, during the entire study period and the number of CTPA needed per diagnostic strategy. RESULTS 740 patients were included. The revised Geneva and Wells PE scores combined with fixed D-dimer cut-off had a diagnostic failure rate of VTE of 0.7 % (95%CI 0.3 %-1.7 %), but >70.0 % of the patients needed imaging. All CTPA-sparing diagnostic algorithms reduced the need for CTPAs (-10.1 % to -32.4 %, depending on the algorithm), at the cost of an increased VTE diagnosis failure rate of up to 2.1 % (95%CI 1.2 %-3.4 %). CONCLUSION Revised Geneva and Wells PE scores combined with fixed D-dimer cut-off were safe, but a high number of CTPA remained needed. CTPA-sparing algorithms would reduce imaging, at the cost of an increased VTE diagnosis failure rate that exceeds the safety threshold. Further studies are needed to improve diagnostic management in this population.
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Affiliation(s)
- Geoffroy Rambaud
- Service des urgences, Centre Hospitalo-Universitaire de Brest, INSERM U1304, Univ_Brest, Brest, FCRIN INNOVTE, France
| | - Vicky Mai
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Camille Motreff
- Centre Hospitalo-Universitaire de Brest, Département de Médecine Interne et Pneumologie, INSERM U1304, CIC INSERM 1412, Univ_Brest, Brest, FCRIN INNOVTE, France
| | - Olivier Sanchez
- Service de Pneumologie et de Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, INSERM UMR S 1140, Université de Paris, Paris, FCRIN INNOVTE, France
| | - Pierre-Marie Roy
- Service des urgences, Centre Hospitalo-Universitaire d'Angers, Institut MITOVASC, EA 3860, Université d'Angers, Angers, FCRIN INNOVTE, France
| | - Yannick Auffret
- Service des urgences, Centre Hospitalo-Universitaire de Brest, INSERM U1304, Univ_Brest, Brest, FCRIN INNOVTE, France
| | - Raphael Le Mao
- Centre Hospitalo-Universitaire de Brest, Département de Médecine Interne et Pneumologie, INSERM U1304, CIC INSERM 1412, Univ_Brest, Brest, FCRIN INNOVTE, France
| | - Frédéric Gagnadoux
- Département de Pneumologie, Centre Hospitalo-Universitaire d'Angers, INSERM UMR1063, Université d'Angers, France
| | - Nicolas Paleiron
- Service de pneumologie-allergologie-cancérologie thoracique, HIA Sainte Anne, Toulon, FCRIN INNOVTE, France
| | - Jeannot Schmidt
- Service des urgences, Centre Hospitalo-Universitaire de Clermont-Ferrand, UMR 6024 UCA-CNRS, Clermont-Ferrand, FCRIN INNOVTE, France
| | - Jean Pastre
- Centre Hospitalo-Universitaire de Brest, Département de Médecine Interne et Pneumologie, INSERM U1304, CIC INSERM 1412, Univ_Brest, Brest, FCRIN INNOVTE, France
| | - Michel Nonent
- Service de radiologie, Centre Hospitalo-Universitaire de Brest, INSERM U1304, Univ_Brest, Brest, FCRIN INNOVTE, France
| | - Cécile Tromeur
- Centre Hospitalo-Universitaire de Brest, Département de Médecine Interne et Pneumologie, INSERM U1304, CIC INSERM 1412, Univ_Brest, Brest, FCRIN INNOVTE, France
| | - Pierre-Yves Salaun
- Centre Hospitalo-Universitaire de Brest, Université de Bretagne Occidentale, Service de Médecine Nucléaire, UMR 1304, Univ_Brest, Brest, FCRIN INNOVTE, France
| | - Patrick Mismetti
- Service de Médecine Vasculaire et Thérapeutique, Centre Hospitalo-Universitaire de Saint-Etienne, INSERM CIC 1408 CHU de St-Etienne, INSERM UMR 1059, Université Jean Monnet, Saint-Etienne, FCRIN INNOVTE, France
| | - Philippe Girard
- Département Thoracique, Institut Mutualiste Montsouris, Paris, FCRIN INNOVTE, France
| | - Karine Lacut
- Centre Hospitalo-Universitaire de Brest, Département de Médecine Interne et Pneumologie, INSERM U1304, CIC INSERM 1412, Univ_Brest, Brest, FCRIN INNOVTE, France
| | - Catherine A Lemarié
- Centre Hospitalo-Universitaire de Brest, Département de Médecine Interne et Pneumologie, INSERM U1304, CIC INSERM 1412, Univ_Brest, Brest, FCRIN INNOVTE, France
| | - Guy Meyer
- Service de Pneumologie et de Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, INSERM UMR S 970, Université de Paris, Paris, FCRIN INNOVTE, France
| | - Christophe Leroyer
- Centre Hospitalo-Universitaire de Brest, Département de Médecine Interne et Pneumologie, INSERM U1304, CIC INSERM 1412, Univ_Brest, Brest, FCRIN INNOVTE, France
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada; Centre Hospitalo-Universitaire de Brest, Département de Médecine Interne et Pneumologie, INSERM U1304, CIC INSERM 1412, Univ_Brest, Brest, FCRIN INNOVTE, France
| | - Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, Centre Hospitalo-Universitaire de Saint-Etienne, INSERM CIC 1408 CHU de St-Etienne, INSERM UMR 1059, Université Jean Monnet, Saint-Etienne, FCRIN INNOVTE, France
| | - Francis Couturaud
- Centre Hospitalo-Universitaire de Brest, Département de Médecine Interne et Pneumologie, INSERM U1304, CIC INSERM 1412, Univ_Brest, Brest, FCRIN INNOVTE, France.
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11
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van Maanen R, Martens ESL, Takada T, Roy PM, de Wit K, Parpia S, Kraaijpoel N, Huisman MV, Wells PS, Le Gal G, Righini M, Freund Y, Galipienzo J, van Es N, Blom JW, Moons KGM, Rutten FH, van Smeden M, Klok FA, Geersing GJ, Luijken K. Accuracy of physicians' intuitive risk estimation in the diagnostic management of pulmonary embolism: an individual patient data meta-analysis. J Thromb Haemost 2023; 21:2873-2883. [PMID: 37263381 DOI: 10.1016/j.jtha.2023.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 05/04/2023] [Accepted: 05/23/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND In patients clinically suspected of having pulmonary embolism (PE), physicians often rely on intuitive estimation ("gestalt") of PE presence. Although shown to be predictive, gestalt is criticized for its assumed variation across physicians and lack of standardization. OBJECTIVES To assess the diagnostic accuracy of gestalt in the diagnosis of PE and gain insight into its possible variation. METHODS We performed an individual patient data meta-analysis including patients suspected of having PE. The primary outcome was diagnostic accuracy of gestalt for the diagnosis of PE, quantified as risk ratio (RR) between gestalt and PE based on 2-stage random-effect log-binomial meta-analysis regression as well as gestalts' sensitivity and specificity. The variability of these measures was explored across different health care settings, publication period, PE prevalence, patient subgroups (sex, heart failure, chronic lung disease, and items of the Wells score other than gestalt), and age. RESULTS We analyzed 20 770 patients suspected of having PE from 16 original studies. The prevalence of PE in patients with and without a positive gestalt was 28.8% vs 9.1%, respectively. The overall RR was 3.02 (95% CI, 2.35-3.87), and the overall sensitivity and specificity were 74% (95% CI, 68%-79%) and 61% (95% CI, 53%-68%), respectively. Although variation was observed across individual studies (I2, 90.63%), the diagnostic accuracy was consistent across all subgroups and health care settings. CONCLUSION A positive gestalt was associated with a 3-fold increased risk of PE in suspected patients. Although variation was observed across studies, the RR of gestalt was similar across prespecified subgroups and health care settings, exemplifying its diagnostic value for all patients suspected of having PE.
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Affiliation(s)
- Rosanne van Maanen
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Emily S L Martens
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands. https://twitter.com/ESLmartens
| | - Toshihiko Takada
- Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima Medical University, Fukushima, Japan
| | - Pierre-Marie Roy
- Department of Emergency Medicine, Angers University Hospital; MitoVasc UMR CNRS 6015 - INSERM 1083, Université Angers, Angers; and French Clinical Research Infrastructure (F-CRIN) Network, INvestigation Network On Venous Thrombo-Embolism (INNOVTE), Saint-Etienne, France
| | - Kerstin de Wit
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Department of Emergency Medicine, Queen's University, Kingston, Canada
| | - Sameer Parpia
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Department of Oncology, McMaster University, Hamilton, Canada
| | - Noémie Kraaijpoel
- Department of Medicine, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Philip S Wells
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Grégoire Le Gal
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Yonathan Freund
- Sorbonne University, Emergency Department, Hopital Pitie-Salpêtrière, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Javier Galipienzo
- Service of Anesthesiology, MD Anderson Cancer Center Madrid, Madrid, Spain
| | - Nick van Es
- Amsterdam UMC location University of Amsterdam, Department of Vascular Medicine, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, the Netherlands
| | - Jeanet W Blom
- Department of General Practice, Leiden University Medical Center, Leiden, the Netherlands
| | - Karel G M Moons
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Frans H Rutten
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Maarten van Smeden
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Geert-Jan Geersing
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Kim Luijken
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Douillet D, Gennai S, Claessens YE, Hachez M, Penaloza A, Sebbane M, Gagnepain A, Morin F, Chauvin A, Montassier E, Thiebaud PC, Violeau M, Andrianjafy H, Savary D, Riou J, Roy PM. Validation of the revised HOME-CoV rule to safely discharge patients with COVID-19: a multicenter prospective cohort. Emergencias 2023; 35:391-394. [PMID: 37801423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 10/08/2023]
Affiliation(s)
- Delphine Douillet
- Emergency Department, Angers University Hospital, Angers, Francia. Univ Angers, UMR MitoVasc CNRS 6015 - INSERM 1083; FCRIN, INNOVTE, Angers, Francia
| | - Stéphane Gennai
- Emergency Department, Reims University Hospital, Reims, Francia
| | - Y-E Claessens
- Emergency Department, Princess Grace Hospital Center, Monaco, Mónaco
| | - M Hachez
- Emergency Department, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Bélgica
| | - Andrea Penaloza
- Emergency Department, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Bélgica
| | - M Sebbane
- Emergency Department, Montpellier University Hospital, Montpellier, Francia
| | - A Gagnepain
- Emergency Department, Libourne Hospital, Libourne, Francia
| | - F Morin
- Univ Angers, UMR MitoVasc CNRS 6015 - INSERM 1083; FCRIN, INNOVTE, Angers, Francia
| | - Anthony Chauvin
- Emergency Department, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, Francia
| | | | - Pierre-Clément Thiebaud
- Emergency Department, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, Paris, Francia
| | | | | | - Dominique Savary
- Emergency Department, Angers University Hospital, Angers, Francia. UNIV Angers, Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S1085, SFR ICAT, CAPTV-CDC, F-49000 Angers, France
| | - Jérémie Riou
- Micro et Nano médecines Translationnelles, MINT, Univ Angers, UMR INSERM 1066, UMR CNRS 6021, Angers, Francia. Methodology and Biostatistics Department, Delegation to Clinical Research and Innovation, Angers University Hospital, 49100 Angers, Francia
| | - Pierre-Marie Roy
- Emergency Department, Angers University Hospital, Angers, Francia. Univ Angers, UMR MitoVasc CNRS 6015 - INSERM 1083; FCRIN, INNOVTE, Angers, Francia
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13
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van Es N, Takada T, Kraaijpoel N, Klok FA, Stals MAM, Büller HR, Courtney DM, Freund Y, Galipienzo J, Le Gal G, Ghanima W, Huisman MV, Kline JA, Moons KGM, Parpia S, Perrier A, Righini M, Robert-Ebadi H, Roy PM, Wells PS, de Wit K, van Smeden M, Geersing GJ. Diagnostic management of acute pulmonary embolism: a prediction model based on a patient data meta-analysis. Eur Heart J 2023; 44:3073-3081. [PMID: 37452732 PMCID: PMC10917087 DOI: 10.1093/eurheartj/ehad417] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/25/2023] [Accepted: 06/13/2023] [Indexed: 07/18/2023] Open
Abstract
AIMS Risk stratification is used for decisions regarding need for imaging in patients with clinically suspected acute pulmonary embolism (PE). The aim was to develop a clinical prediction model that provides an individualized, accurate probability estimate for the presence of acute PE in patients with suspected disease based on readily available clinical items and D-dimer concentrations. METHODS AND RESULTS An individual patient data meta-analysis was performed based on sixteen cross-sectional or prospective studies with data from 28 305 adult patients with clinically suspected PE from various clinical settings, including primary care, emergency care, hospitalized and nursing home patients. A multilevel logistic regression model was built and validated including ten a priori defined objective candidate predictors to predict objectively confirmed PE at baseline or venous thromboembolism (VTE) during follow-up of 30 to 90 days. Multiple imputation was used for missing data. Backward elimination was performed with a P-value <0.10. Discrimination (c-statistic with 95% confidence intervals [CI] and prediction intervals [PI]) and calibration (outcome:expected [O:E] ratio and calibration plot) were evaluated based on internal-external cross-validation. The accuracy of the model was subsequently compared with algorithms based on the Wells score and D-dimer testing. The final model included age (in years), sex, previous VTE, recent surgery or immobilization, haemoptysis, cancer, clinical signs of deep vein thrombosis, inpatient status, D-dimer (in µg/L), and an interaction term between age and D-dimer. The pooled c-statistic was 0.87 (95% CI, 0.85-0.89; 95% PI, 0.77-0.93) and overall calibration was very good (pooled O:E ratio, 0.99; 95% CI, 0.87-1.14; 95% PI, 0.55-1.79). The model slightly overestimated VTE probability in the lower range of estimated probabilities. Discrimination of the current model in the validation data sets was better than that of the Wells score combined with a D-dimer threshold based on age (c-statistic 0.73; 95% CI, 0.70-0.75) or structured clinical pretest probability (c-statistic 0.79; 95% CI, 0.76-0.81). CONCLUSION The present model provides an absolute, individualized probability of PE presence in a broad population of patients with suspected PE, with very good discrimination and calibration. Its clinical utility needs to be evaluated in a prospective management or impact study. REGISTRATION PROSPERO ID 89366.
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Affiliation(s)
- Nick van Es
- Amsterdam University Medical Center, Department of Vascular Medicine, University of Amsterdam, Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands
- Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1247, Japan
| | - Noémie Kraaijpoel
- Amsterdam University Medical Center, Department of Vascular Medicine, University of Amsterdam, Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, Zuid-Holland, The Netherlands
| | - Milou A M Stals
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, Zuid-Holland, The Netherlands
| | - Harry R Büller
- Amsterdam University Medical Center, Department of Vascular Medicine, University of Amsterdam, Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - D Mark Courtney
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Yonathan Freund
- Emergency Department, Sorbonne University, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Bd de l'Hôpital, 75013 Paris, France
| | - Javier Galipienzo
- Service of Anesthesiology, MD Anderson Cancer Center Madrid, C. de Arturo Soria, 270, 28033 Madrid, Spain
| | - Grégoire Le Gal
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, ON K1Y 4E9, Canada
| | - Waleed Ghanima
- Departments of Hemato-oncology and Research, Østfold hospital, Kalnesveien 300, 1714 Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Klaus Torgårds vei 3, 0372 Oslo, Oslo, Norway
| | - Menno V Huisman
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, Zuid-Holland, The Netherlands
| | - Jeffrey A Kline
- Department of Emergency Medicine, Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 4820, USA
| | - Karel G M Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands
| | - Sameer Parpia
- Department of Health Research Methods, Evidence, & Impact, McMaster University, 1200 Main St W, Hamilton, ON L8N 3Z5, Canada
- Department of Oncology, McMaster University, Juravinski Cancer Centre, 699 Concession St. Suite 4-204, Hamilton, Ontario, Canada
| | - Arnaud Perrier
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Rue Michel-Servet 1, 1206 Genève, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Rue Michel-Servet 1, 1206 Genève, Switzerland
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Rue Michel-Servet 1, 1206 Genève, Switzerland
| | - Pierre-Marie Roy
- Emergency Department, CHU Angers, UNIV Angers, 4 Rue Larrey, 49100 Angers, Maine-et-Loire, France
| | - Phil S Wells
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, ON K1Y 4E9, Canada
| | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University, 76 Stuart Street, Kingston ON K7L 2V7, Canada
- Department of Medicine, McMaster University, McMaster Children's Hospital, 1200 Main Street West, Hamilton, L8N 3Z5 Ontario, Canada
- Department of Health Evidence and Impact, McMaster University, 1200 Main St W, Hamilton, ON L8N 3Z5, Canada
| | - Maarten van Smeden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands
| | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands
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14
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Robert-Ebadi H, Roy PM, Sanchez O, Verschuren F, Le Gal G, Righini M. External validation of the PEGeD diagnostic algorithm for suspected pulmonary embolism in an independent cohort. Blood Adv 2023; 7:3946-3951. [PMID: 36521170 PMCID: PMC10410134 DOI: 10.1182/bloodadvances.2022007729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 10/18/2022] [Accepted: 10/18/2022] [Indexed: 12/23/2022] Open
Abstract
Sequential diagnostic algorithms are used in the case of suspected pulmonary embolism (PE). The PEGeD study proposed a new diagnostic strategy to reduce the use of computed tomography pulmonary angiography (CTPA). We aimed to externally validate this diagnostic strategy in an independent cohort. We analyzed data from 3 prospective studies of outpatients with suspected PE. As per the PEGeD algorithm, patients were classified as having a low, moderate, or high clinical pretest probability (C-PTP). PE was excluded with a D-dimer <1000 ng/mL in case of low C-PTP and <500 ng/mL in case of moderate C-PTP. We assessed the yield and safety of this approach and compared them with those of previously validated algorithms. Among the 3308 evaluated patients, 1615 (49%) patients could have had PE excluded according to the PEGeD algorithm, without the need for imaging. Of these patients, 38 (2.3%; 95% confidence interval [CI], 1.7-3.2) were diagnosed with a symptomatic PE at initial testing or during the 3-month follow-up. On further analysis, 36 patients out of these 38 patients had a positive age-adjusted D-dimer. The risk of venous thromboembolic events among the 414 patients with a D-dimer <1000 ng/mL but above the age-adjusted D-dimer cut-off was 36 of 414 (8.7%; 95% CI, 6.4-11.8). We provide external validation of the PEGeD algorithm in an independent cohort. Compared with standard algorithms, the PEGeD decreased the number of CTPA examinations. However, caution is required in patients with a low C-PTP and a D-dimer <1000 ng/mL but above their age-adjusted D-dimer cut-off.
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Affiliation(s)
- Helia Robert-Ebadi
- Division of Angiology and Hemostasis and Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre-Marie Roy
- Department of Emergency Medicine, University Hospital of Angers, Angers, France
| | - Olivier Sanchez
- Department of Respiratory Disease, Hôpital Européen Georges Pompidou, APHP, and Université Paris Descartes, Paris, France
| | - Frank Verschuren
- Emergency Department, Saint-Luc University Hospital, Brussels, Belgium
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Marc Righini
- Division of Angiology and Hemostasis and Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
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15
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Zuily S, Lefèvre B, Sanchez O, Empis de Vendin O, de Ciancio G, Arlet JB, Khider L, Terriat B, Greigert H, Robert CS, Louis G, Trinh-Duc A, Rispal P, Accassat S, Thiery G, Montani D, Azarian R, Meneveau N, Soudet S, Le Mao R, Maurier F, Le Moing V, Quéré I, Yelnik CM, Lefebvre N, Martinot M, Delrue M, Benhamou Y, Parent F, Roy PM, Presles E, Goehringer F, Mismetti P, Bertoletti L, Rossignol P, Couturaud F, Wahl D, Thilly N, Laporte S. Effect of weight-adjusted intermediate-dose versus fixed-dose prophylactic anticoagulation with low-molecular-weight heparin on venous thromboembolism among noncritically and critically ill patients with COVID-19: the COVI-DOSE trial, a multicenter, randomised, open-label, phase 4 trial. EClinicalMedicine 2023; 60:102031. [PMID: 37350990 PMCID: PMC10250778 DOI: 10.1016/j.eclinm.2023.102031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/12/2023] [Accepted: 05/16/2023] [Indexed: 06/24/2023] Open
Abstract
Background Venous thromboembolism is a major complication of coronavirus disease 2019 (COVID-19). We hypothesized that a weight-adjusted intermediate dose of anticoagulation may decrease the risk of venous thromboembolism COVID-19 patients. Methods In this multicenter, randomised, open-label, phase 4, superiority trial with blinded adjudication of outcomes, we randomly assigned adult patients hospitalised in 20 French centers and presenting with acute respiratory SARS-CoV-2. Eligible patients were randomly assigned (1:1 ratio) to receive an intermediate weight-adjusted prophylactic dose or a fixed-dose of subcutaneous low-molecular-weight heparin during the hospital stay. The primary outcome corresponded to symptomatic deep-vein thrombosis (fatal) pulmonary embolism during hospitalization (COVI-DOSE ClinicalTrials.gov number: NCT04373707). Findings Between May 2020, and April 2021, 1000 patients underwent randomisation in medical wards (noncritically ill) (80.1%) and intensive care units (critically ill) (19.9%); 502 patients were assigned to receive a weight-adjusted intermediate dose, and 498 received fixed-dose thromboprophylaxis. Symptomatic venous thromboembolism occurred in 6 of 502 patients (1.2%) in the weight-adjusted dose group and in 10 of 498 patients (2.1%) in the fixed-dose group (subdistribution hazard ratio, 0.59; 95% CI, 0.22-1.63; P = 0.31). There was a twofold increased risk of major or clinically relevant nonmajor bleeding: 5.9% in the weight-adjusted dose group and 3.1% in the fixed-dose group (P = 0.034). Interpretation In the COVI-DOSE trial, the observed rate of thromboembolic events was lower than expected in patients hospitalized for COVID-19 infection, and the study was unable to show a significant difference in the risk of venous thromboembolism between the two low-molecular-weight-heparin regimens. Funding French Ministry of Health, CAPNET, Grand-Est Region, Grand-Nancy Métropole.
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Affiliation(s)
- Stéphane Zuily
- Vascular Medicine Division, Université de Lorraine, CHRU-Nancy, Rare Vascular and Systemic Autoimmune Diseases Regional Referral Center, France
- Inserm, UMR 1116 DCAC, F-54000 Nancy, France
- F-CRIN INNOVTE Network, F-42000 Saint-Etienne, France
| | - Benjamin Lefèvre
- Department of Infectious and Tropical Diseases, Université de Lorraine, CHRU-Nancy, APEMAC, F-54000 Nancy, France
| | - Olivier Sanchez
- Department of Respiratory and Intensive Care Medicine, Université Paris Cité, AP-HP, Hôpital Européen Georges Pompidou, F-75015 Paris, France
- F-CRIN INNOVTE Network, F-42000 Saint-Etienne, France
- Inserm, Innovative Therapies in Haemostasis, Paris, France
| | | | | | - Jean-Benoît Arlet
- Internal Medicine Department, AP-HP, Hôpital Européen Georges Pompidou, APHP, F-75015 Paris, France
| | - Lina Khider
- Vascular Medicine Department, Université de Paris, AP-HP, Hôpital Européen Georges Pompidou, F-75015 Paris, France
| | - Béatrice Terriat
- Department of Vascular Medicine and Angiology, Dijon University Hospital, F-21000 Dijon, France
| | - Hélène Greigert
- Department of Vascular Medicine and Angiology, Dijon University Hospital, F-21000 Dijon, France
| | - Céline S Robert
- Department of Infectious Diseases, CHR Metz-Thionville, F-57000 Metz, France
| | - Guillaume Louis
- Intensive Care Unit, CHR Metz-Thionville, F-57000 Metz, France
| | - Albert Trinh-Duc
- Internal Medicine Department, CH St Esprit, F-47000 Agen, France
| | - Patrick Rispal
- Internal Medicine Department, CH St Esprit, F-47000 Agen, France
| | - Sandrine Accassat
- Department of Vascular Medicine, CHU Saint-Etienne, F-42000 Saint-Etienne, France
| | - Guillaume Thiery
- Medical Intensive Care Unit, CHU Saint-Etienne, F-42000 Saint-Etienne, France
| | - David Montani
- Department of Respiratory and Intensive Care Medicine, Université Paris-Saclay, AP-HP, Hôpital Bicêtre, Pulmonary Hypertension National Referral Center, F-94270 Le Kremlin-Bicêtre, France
| | - Réza Azarian
- Department of Respiratory Medicine, CH Versailles, F-78150 Le Chesnay, France
| | - Nicolas Meneveau
- Department of Cardiology, Université de Franche-Comté, CHU Jean Minjoz, EA 3929, F-25000 Besancon, France
| | - Simon Soudet
- Department of Vascular Medicine, CHU Amiens-Picardie, F-80000 Amiens, France
| | - Raphaël Le Mao
- Department of Internal Medicine, Vascular Medicine and Pulmonology, CHU Brest, F-29200 Brest, France
| | - François Maurier
- Department of Internal Medicine, UNEOS, F-57070 Metz-Vantoux, France
| | - Vincent Le Moing
- Department of Infectious and Tropical Diseases, CHRU Montpellier, F-34000 Montpellier, France
| | - Isabelle Quéré
- Department of Vascular Medicine, CHU Montpellier, IDESP, F-34000 Montpellier, France
| | - Cécile M Yelnik
- Department of Internal Medicine and Clinical Immunology, Université de Lille, CHU Lille, Inserm UMR 1167, North and North-West Systemic and Autoimmune Disease National Referral Center (CeRAINO), F-59000 Lille, France
| | - Nicolas Lefebvre
- Department of Tropical and Infectious Diseases, Hôpitaux Universitaires de Strasbourg, F-67000 Strasbourg, France
| | - Martin Martinot
- Department of Tropical and Infectious Diseases, Hôpitaux Civils de Colmar, F-68000 Colmar, France
| | - Maxime Delrue
- Hematology Laboratory and Thrombosis Unit, Lariboisière Hospital, APHP, Paris, France
| | - Ygal Benhamou
- Department of Internal Medicine, Normandie Université, Université de Rouen Normandie, Inserm UMR 1096, F-76000 Rouen, France
| | - Florence Parent
- Department of Respiratory and Intensive Care Medicine, Université Paris-Saclay, AP-HP, Hôpital Bicêtre, Pulmonary Hypertension National Referral Center, F-94270 Le Kremlin-Bicêtre, France
| | - Pierre-Marie Roy
- Department of Emergency Medicine, Université d'Angers, CHU Angers, F-49000 Angers, France
| | - Emilie Presles
- Université Jean Monnet, Inserm, U1059 SAINBIOSE, France
- F-CRIN INNOVTE Network, F-42000 Saint-Etienne, France
- CHU Saint-Etienne, Unité de Recherche Clinique, Innovation, Pharmacologie, France
| | - François Goehringer
- Department of Infectious and Tropical Diseases, CHRU-Nancy, F-54000 Nancy, France
| | - Patrick Mismetti
- Université Jean Monnet, Inserm, U1059 SAINBIOSE, France
- F-CRIN INNOVTE Network, F-42000 Saint-Etienne, France
- CHU Saint-Etienne, Unité de Recherche Clinique, Innovation, Pharmacologie, Service de Médecine Vasculaire et Thérapeutique, France
| | - Laurent Bertoletti
- Université Jean Monnet, Inserm, CIC-1408, CHU Saint-Etienne, Service de Médecine Vasculaire et Thérapeutique, France
- F-CRIN INNOVTE Network, F-42000 Saint-Etienne, France
| | - Patrick Rossignol
- Université de Lorraine, Inserm, CIC-P 1433, CHRU-Nancy, Inserm UMR 1116, F-CRIN INI-CRCT, F-54000 Nancy, France
- Department of Medical Specialties and Nephrology-Hemodialysis, Princess Grace Hospital, and Centre d'Hémodialyse Privé de Monaco, Monaco
| | - Francis Couturaud
- Department of Internal Medicine and Chest Diseases, Université de Bretagne Occidentale, CHU Brest, France
- F-CRIN INNOVTE Network, F-42000 Saint-Etienne, France
- Inserm UMR 1304 GETBO, F-29200 Brest, France
| | - Denis Wahl
- Vascular Medicine Division, Université de Lorraine, CHRU-Nancy, Rare Vascular and Systemic Autoimmune Diseases Regional Referral Center, France
| | - Nathalie Thilly
- Département Méthodologie, Promotion, Investigation, Université de Lorraine, CHRU-Nancy, APEMAC, , F-54000 Nancy, France
| | - Silvy Laporte
- Université Jean Monnet, Inserm, U1059 SAINBIOSE, France
- F-CRIN INNOVTE Network, F-42000 Saint-Etienne, France
- CHU Saint-Etienne, Unité de Recherche Clinique, Innovation, Pharmacologie, France
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16
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Roy PM, Moumneh T, Bizouard T, Duval D, Douillet D. How to Combat Over-Testing for Patients Suspected of Pulmonary Embolism: A Narrative Review. Diagnostics (Basel) 2023; 13:diagnostics13071326. [PMID: 37046544 PMCID: PMC10093278 DOI: 10.3390/diagnostics13071326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/26/2023] [Accepted: 03/30/2023] [Indexed: 04/05/2023] Open
Abstract
The diagnosis of PE remains difficult in 2023 because the signs and symptoms are not sensible nor specific. The consequences of potential diagnostic errors can be dramatic, whether by default or by excess. Furthermore, the achievement of a simple diagnostic strategy, based on clinical probability assessment, D-dimer measurement and computed tomography pulmonary angiography (CTPA) leads to a new challenge for PE diagnosis: over-testing. Indeed, since the 2000s, the wide availability of CTPA resulted in a major increase in investigations with a mod I confirm erate increase in PE diagnosis, without any notable improvement in patient outcomes. Quite the contrary, the complications of anticoagulation for PE increased significantly, and the long-term consequences of imaging diagnostic radiation is an important concern, especially the risk of breast cancer for young women. As a result, several strategies have been proposed to fight over-testing. They are mostly based on defining a subgroup of patients for whom no specific exam should be required to rule-out PE and adjusting the D-dimer cutoff to allow the exclusion of PE without performing CTPA. This narrative review presents the advantages and limitations of these different strategies as well as the perspective in PE diagnosis.
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Affiliation(s)
- Pierre-Marie Roy
- Department of Emergency Medicine, University Hospital of Angers, Avenue of the Hotel Dieu, 49100 Angers, France
- UMR MitoVasc CNRS 6215 INSERM 1083, University Angers, 49100 Angers, France
- FCRIN, INNOVTE, 42023 Saint-Étienne, France
| | - Thomas Moumneh
- Department of Emergency Medicine, University Hospital of Tours, Avenue of the Republic, 37044 Tours, France
| | - Thomas Bizouard
- Department of Emergency Medicine, University Hospital of Angers, Avenue of the Hotel Dieu, 49100 Angers, France
| | - Damien Duval
- Department of Emergency Medicine, University Hospital of Angers, Avenue of the Hotel Dieu, 49100 Angers, France
| | - Delphine Douillet
- Department of Emergency Medicine, University Hospital of Angers, Avenue of the Hotel Dieu, 49100 Angers, France
- UMR MitoVasc CNRS 6215 INSERM 1083, University Angers, 49100 Angers, France
- FCRIN, INNOVTE, 42023 Saint-Étienne, France
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Delvau N, Penaloza A, Franssen V, Thys F, Roy PM, Hantson P. Unexpected carboxyhemoglobin half-life during cardiopulmonary resuscitation: a case report. Int J Emerg Med 2023; 16:22. [PMID: 36944931 PMCID: PMC10029238 DOI: 10.1186/s12245-023-00492-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/26/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Cardiac arrest (CA) following CO poisoning (CO-induced CA) exposes patients to an extremely high risk of mortality and remains challenging to treat effectively. Terminal carboxyhemoglobin elimination half-life (COHbt1/2) is critically affected by ventilation, oxygen therapy, and cardiac output, which are severely affected conditions in cases of CA. CASE PRESENTATION Asystole occurred in an 18-year-old woman after unintentional exposure to CO in her bathroom. Cardiopulmonary resuscitation (CPR) was started immediately, including mechanical ventilation with a fraction of inspired oxygen (FiO2) of 1.0 and external chest compressions with a LUCAS® device. CPR was stopped after 101 min, as it was unsuccessful. During this period, we calculated a COHbt1/2 of 40.3 min using a single compartmental model. CONCLUSIONS This result suggests that prolongation of CPR time needed to back COHb at 10%, a level more compatible with successful return of spontaneous circulation (ROSC), could be compatible with a realistic CPR time. Calculating COHbt1/2 during CPR may help with decision-making regarding the optimal duration of resuscitation efforts and further with HBO2 or ECLS. Further evidence-based data are needed to confirm this result.
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Affiliation(s)
- Nicolas Delvau
- Departments of Emergency Care, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 1200, Brussels, Belgium.
| | - Andrea Penaloza
- Departments of Emergency Care, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 1200, Brussels, Belgium
| | - Véronique Franssen
- Departments of Emergency Care, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 1200, Brussels, Belgium
| | - Frédéric Thys
- Emergency Department, GHDC: Grand Hopital de Charleroi, 6000, Charleroi, Belgium
| | - Pierre-Marie Roy
- Emergency Department, CHU Angers: Centre Hospitalier Universitaire d'Angers, Angers Cedex 01, 49033, Angers, France
| | - Philippe Hantson
- Departments of Intensive Care, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 1200, Brussels, Belgium
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18
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Stals MAM, Moumneh T, Ainle FN, Aujesky D, van Bemmel T, Bertoletti L, Bistervels IM, Chauleur C, Couturaud F, van Dooren YPA, Elias A, Faber LM, Le Gall C, Hofstee HMA, van der Hulle T, Kruip MJHA, Maignan M, Mairuhu ATA, Middeldorp S, Le Moigne E, Nijkeuter M, van der Pol LM, Robert-Ebadi H, Roy PM, Sanchez O, Schmidt J, van Smeden M, Tromeur C, Wolde MT, Righini M, Le Gal G, Huisman MV, Klok FA. Noninvasive diagnostic work-up for suspected acute pulmonary embolism during pregnancy: a systematic review and meta-analysis of individual patient data. J Thromb Haemost 2023; 21:606-615. [PMID: 36696189 DOI: 10.1016/j.jtha.2022.11.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 11/11/2022] [Accepted: 11/15/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Few studies evaluated the performance of noninvasive diagnostic strategies for suspected acute pulmonary embolism (PE) in pregnant women. OBJECTIVES The aim of this study was to establish the safety and efficiency of the Wells rule with fixed and adapted D-dimer threshold, and the YEARS algorithm, combined with compression ultrasonography (CUS), in pregnant women with suspected PE in an individual patient data meta-analysis. METHODS We performed a systematic review to identify prospective diagnostic management studies in pregnant women with suspected PE. Primary outcomes were safety, defined as the failure rate, ie, the 3-month venous thromboembolism (VTE) incidence after excluding PE without chest imaging, and efficiency, defined as the proportion of patients in whom chest imaging could be avoided. RESULTS We identified 2 relevant studies, of which individual patient-level data were analyzed in a fixed-effect meta-analysis, totaling 893 pregnant women. The Wells rule with fixed and adapted D-dimer threshold as well as the YEARS algorithm could safely rule out acute PE (failure rate, 0·37%-1·4%), but efficiency improved considerably when applying pretest probability-adapted D-dimer thresholds. The efficiency of bilateral CUS was limited (2·3% overall; number needed to test 43), especially in patients without symptoms of deep-vein thrombosis (efficiency 0·79%; number needed to test 127). CONCLUSION This study supports the latest guideline recommendations (European Society of Cardiology 2019) to apply pretest probability assessment and D-dimer tests to rule out PE in pregnant women. From an efficiency perspective, the use of a strategy with pretest probability-adapted D-dimer threshold is preferred. The yield of CUS was very limited in patients without concomitant symptoms of deep-vein thrombosis.
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Affiliation(s)
- Milou A M Stals
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Thomas Moumneh
- Department of Emergency Medicine, CHU Angers, University Hospital of Angers, UMR MitoVasc CNRS 6015 - INSERM 1083, Equipe CARME, Angers, France; F-CRIN INNOVTE research network, Saint-Etienne, France
| | - Fionnuala Ni Ainle
- Department of Hematology, Mater Misericordiae University Hospital, Dublin, and School of Medicine, University College Dublin, Ireland
| | - Drahomir Aujesky
- Division of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas van Bemmel
- Department of Internal Medicine, Gelre Ziekenhuizen Apeldoorn, Apeldoorn, the Netherlands
| | - Laurent Bertoletti
- F-CRIN INNOVTE research network, Saint-Etienne, France; Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France; CIC 1408 Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France University Jean Monnet, University Hospital of Saint-Etienne, Mines Saint-Etienne, INSERM U 1059, Saint-Etienne, France
| | - Ingrid M Bistervels
- Department of Internal Medicine, Flevo Hospital, Almere, the Netherlands; Department of Vascular Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Céline Chauleur
- Department of Obstetrics and Gynaecology, CHU de St-Etienne, Saint-Etienne, France; CIC 1408 Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France University Jean Monnet, University Hospital of Saint-Etienne, Mines Saint-Etienne, INSERM U 1059, Saint-Etienne, France
| | - Francis Couturaud
- F-CRIN INNOVTE research network, Saint-Etienne, France; Department of Internal Medicine and Chest Diseases, Brest Hospital Center, Groupe d'Etude de Thrombose de Bretagne Occidentale, INSERM UMR1304, University of Brest, Brest, France
| | | | - Antoine Elias
- F-CRIN INNOVTE research network, Saint-Etienne, France; Médecine Vasculaire, Centre Hospitalier de Toulon, Toulon, France
| | - Laura M Faber
- Department of Internal Medicine, Red Cross Hospital, Beverwijk, the Netherlands
| | - Catherine Le Gall
- F-CRIN INNOVTE research network, Saint-Etienne, France; Centre Hospitalier d'Argenteuil, Argenteuil, France
| | - Herman M A Hofstee
- Department of Internal Medicine, Haaglanden Medical Center, The Hague, the Netherlands
| | - Tom van der Hulle
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Marieke J H A Kruip
- Department of Hematology Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Maxime Maignan
- Department of Emergency, CHU Grenoble-Alpes, Hypoxy-Physiopathology laboratory HP2, Grenoble, France
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands
| | - Saskia Middeldorp
- Department of Internal Medicine and Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Emmanuelle Le Moigne
- F-CRIN INNOVTE research network, Saint-Etienne, France; Department of Internal Medicine and Chest Diseases, Brest Hospital Center, Groupe d'Etude de Thrombose de Bretagne Occidentale, INSERM UMR1304, University of Brest, Brest, France
| | - Mathilde Nijkeuter
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Liselotte M van der Pol
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Helia Robert-Ebadi
- F-CRIN INNOVTE research network, Saint-Etienne, France; Department of Medicine, Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Pierre-Marie Roy
- Department of Emergency Medicine, CHU Angers, University Hospital of Angers, UMR MitoVasc CNRS 6015 - INSERM 1083, Equipe CARME, Angers, France; F-CRIN INNOVTE research network, Saint-Etienne, France
| | - Olivier Sanchez
- F-CRIN INNOVTE research network, Saint-Etienne, France; Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Jeannot Schmidt
- F-CRIN INNOVTE research network, Saint-Etienne, France; Department of Emergency, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Maarten van Smeden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Cecile Tromeur
- F-CRIN INNOVTE research network, Saint-Etienne, France; Department of Internal Medicine and Chest Diseases, Brest Hospital Center, Groupe d'Etude de Thrombose de Bretagne Occidentale, INSERM UMR1304, University of Brest, Brest, France
| | - Marije Ten Wolde
- Department of Internal Medicine, Flevo Hospital, Almere, the Netherlands
| | - Marc Righini
- Department of Medicine, Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Grégoire Le Gal
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Thrombosis Research Group, Ottawa, Canada
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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Bouget J, Balusson F, Roy PM, Viglino D, Pavageau L, Lacut K, Oger E. Management of epistaxis associated with oral antithrombotic drugs in emergency department and impact on prescription thereafter. Clin Otolaryngol 2023; 48:457-464. [PMID: 36789614 DOI: 10.1111/coa.14040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/25/2022] [Accepted: 01/21/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVES To describe management, and to assess factors associated with antithrombotic prescription thereafter in patients who had epistaxis referred to emergency department (ED). DESIGN Prospective cohort study. From EDs, clinical, biological and hospital data were collected. The clinical database was linked to the French Health Insurance Database where we retrieved antithrombotic drug deliveries in a 3-month period before and after referral. SETTING Multicentric population-based cohort study within five well-defined areas. PARTICIPANTS We considered 306 patients referred for epistaxis with a stable oral antithrombotic regimen before referral. MAIN OUTCOME MEASURES We considered management, hospital outcome and case fatality. Antithrombotic prescription in a 3-month follow-up period was categorised into three classes: no change, class change, or discontinuation. During follow-up, hospitalisation for epistaxis or ischaemic events was searched. RESULTS Among 306 adult individuals (mean age: 76 years), 166 took oral anticoagulant and 140 an antiplatelet drug. Blood transfusion was needed in 13.7% of patients and anterior packing alone in 61%. Half of the patients were hospitalised; 301 were discharged alive. Considering antithrombotic prescription thereafter we observed no change in 219 patients (72.8%), class changes in 47 patients (15.6%) and discontinuation in 35 patients (11.6%). We identified four independent predictors for antithrombotic prescription: hospitalisation (vs. returning home, p = .05), age (p = .03), haemoglobin level (p = .03) and oral anticoagulant (vs. antiplatelet agent, p < .001). During the 3 months following discharge, 2 thrombotic and 15 bleeding events were identified. CONCLUSIONS Epistaxis referred to emergency department had an impact on subsequent antithrombotic prescription. CLINICAL TRIAL REGISTRATION Clinical Trials.gov identifier: NCT02886533.
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Affiliation(s)
- Jacques Bouget
- Univ Rennes, CHU Rennes, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Rennes, France.,Emergency Department, Rennes University Hospital, Rennes, France
| | - Frédéric Balusson
- Univ Rennes, CHU Rennes, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Rennes, France
| | - Pierre-Marie Roy
- Emergency Department, Centre Hospitalier Universitaire, Institut MITOVASC, Université d'Angers, Angers, France.,F-CRIN INNOVTE, Paris, France
| | - Damien Viglino
- Emergency Department, Grenoble-Alpes University Hospital, Grenoble, France
| | - Laure Pavageau
- Emergency Department, University hospital, Nantes, France
| | - Karine Lacut
- CIC 1412, Université de Bretagne Loire, Université de Brest, INSERM CIC 1412, CHRU de Brest, Brest, France
| | - Emmanuel Oger
- Univ Rennes, CHU Rennes, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Rennes, France
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20
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Morin F, Douillet D, Hamel JF, Savary D, Aubé C, Tazarourte K, Marouf K, Dupriez F, Le Conte P, Flament T, Delomas T, Taalba M, Marjanovic N, Couturaud F, Peschanski N, Boishardy T, Riou J, Dubée V, Roy PM. Point-of-care ultrasonography for risk stratification of non-critical suspected COVID-19 patients on admission (POCUSCO): A prospective binational study. PLoS One 2023; 18:e0284748. [PMID: 37099493 PMCID: PMC10132646 DOI: 10.1371/journal.pone.0284748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 04/07/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND Lung point-of-care ultrasonography (L-POCUS) is highly effective in detecting pulmonary peripheral patterns and may allow early identification of patients who are likely to develop an acute respiratory distress syndrome (ARDS). We hypothesized that L-POCUS performed within the first 48 hours of non-critical patients with suspected COVID-19 would identify those with a high-risk of worsening. METHODS POCUSCO was a prospective, multicenter study. Non-critical adult patients who presented to the emergency department (ED) for suspected or confirmed COVID-19 were included and had L-POCUS performed within 48 hours following ED presentation. The lung damage severity was assessed using a previously developed score reflecting both the extension and the intensity of lung damage. The primary outcome was the rate of patients requiring intubation or who died within 14 days following inclusion. RESULTS Among 296 patients, 8 (2.7%) met the primary outcome. The area under the curve (AUC) of L-POCUS was 0.80 [95%CI:0.60-0.94]. The score values which achieved a sensibility >95% in defining low-risk patients and a specificity >95% in defining high-risk patients were <1 and ≥16, respectively. The rate of patients with an unfavorable outcome was 0/95 (0%[95%CI:0-3.9]) for low-risk patients (score = 0), 4/184 (2.17%[95%CI:0.8-5.5]) for intermediate-risk patients (score 1-15) and 4/17 (23.5%[95%CI:11.4-42.4]) for high-risk patients (score ≥16). In confirmed COVID-19 patients (n = 58), the AUC of L-POCUS was 0.97 [95%CI:0.92-1.00]. CONCLUSION L-POCUS performed within the first 48 hours following ED presentation allows risk-stratification of patients with non-severe COVID-19.
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Affiliation(s)
- François Morin
- Department of Emergency Medicine, University Hospital of Angers, Angers, France
| | - Delphine Douillet
- Department of Emergency Medicine, University Hospital of Angers, Angers, France
- UNIV Angers, UMR MitoVasc CNRS 6215 INSERM 1083, Angers, France
| | - Jean François Hamel
- Department of Methodology and Biostatistics, University Hospital of Angers, Univ Angers, Angers, France
- UNIV Angers, IRSET (Institut de Recherche en Santé, Environnement et Travail) - UMR_S 1085, Angers, France
| | - Dominique Savary
- Department of Emergency Medicine, University Hospital of Angers, Angers, France
- UNIV Angers, IRSET (Institut de Recherche en Santé, Environnement et Travail) - UMR_S 1085, Angers, France
| | - Christophe Aubé
- Department of Radiology, University Hospital of Angers, Univ Angers, Angers, France
| | - Karim Tazarourte
- Claude Bernard University of Lyon, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France
- Emergency Department, Groupement Hospitalier Édouard-Herriot, Hospices Civils de Lyon, Lyon, France
| | - Kamélia Marouf
- Department of Emergency Medicine, Hospital of Cholet, Cholet, France
| | - Florence Dupriez
- Department of Emergency Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Phillipe Le Conte
- Department of Emergency Medicine, University Hospital of Nantes, Nantes, France
| | - Thomas Flament
- Department of Pulmonology University Hospital of Tours, Tours, France
- Société de Pneumologie de Langue Française, Chest Ultrasound Working Group (GECHO), France
| | - Thomas Delomas
- Department of Emergency Medicine, Hospital of Saint-Lo, Saint-Lo, France
| | - Mehdi Taalba
- Department of Emergency Medicine, University Hospital of Rouen, Rouen, France
| | - Nicolas Marjanovic
- Faculté de Médecine et de Pharmacie, Univ Poitiers, Poitiers, France
- Department of Emergency Medicine, University Hospital of Poitiers, Poitiers, France
- INSERM CIC1402 Team 5 - Acute Lung Injury and Ventilatory Support, France
| | - Francis Couturaud
- Department of Internal Medicine and Chest Diseases, CHU Brest, EA3878, Univ Brest, Brest, France
| | - Nicolas Peschanski
- Department of Emergency Medicine, University Hospital of Rennes, Rennes, France
| | - Thomas Boishardy
- Department of Emergency Medicine, University Hospital of Angers, Angers, France
| | - Jérémie Riou
- UNIV Angers INSERM, UMR 1066, CNRS 6021, MINT, Angers, France
| | - Vincent Dubée
- Infectious Diseases Department, University Hospital of Angers, Angers, France
- CRCINA, Univ Angers, Univ Nantes, Inserm, Nantes, France
| | - Pierre-Marie Roy
- Department of Emergency Medicine, University Hospital of Angers, Angers, France
- UNIV Angers, UMR MitoVasc CNRS 6215 INSERM 1083, Angers, France
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21
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Moumneh T, Penaloza A, Charpentier S, Douillet D, Prunier F, Riou J, Roy PM. Efficacy of HEAR and HEART score to rule out major adverse cardiac events in patients presenting to the emergency department with chest pain: study protocol of the eCARE stepped-wedge randomised control trial. BMJ Open 2022; 12:e066953. [PMID: 36600358 PMCID: PMC9730388 DOI: 10.1136/bmjopen-2022-066953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Current guidelines for patients presenting to the emergency department (ED) with chest pain without ST-segment elevation myocardial infarction (STEMI) on ECG are based on serial troponin measurements. A clinical tool able to identify very low-risk patients who could forgo a troponin test and low-risk patients requiring only one troponin measurement would be of great interest. To do so, the HEAR and HEART score, standing for history, ECG, age, risk factors±troponin were prospectively assessed, but not combined and implemented in clinical practice. The objective of the eCARE study is to assess the impact of implementing a diagnostic strategy based on a HEAR score <2 or a HEART score <4 (HEAR-T strategy) to rule out non-STEMI without or with a single troponin measurement in patients presenting to the ED with chest pain without obvious diagnosis after physical examination and an ECG. METHODS AND ANALYSIS Stepped-wedge cluster-randomised control trial in 10 EDs. Patients with non-traumatic chest pain and no formal diagnosis were included and followed for 30 days. In the interventional phase, the doctor will be asked not to perform a troponin test to look for an acute coronary if the HEAR score is <2 and not to perform an additional troponin test if the HEAR score is ≥2 and HEART score is <4. The main endpoint is the non-inferiority of the rates of major adverse cardiac events occurring between a patient's discharge and the 30-day follow-up against current recommended guidelines. ETHICS AND DISSEMINATION The study was approved by an institutional review board for all participating centres. If successful, the eCARE study will cover a gap in the evidence, proving that it is safe and efficient to rule out the hypothesis of an acute myocardial infarction in some selected very low-risk patients or based on a single troponin measurement in some low-risk patients. TRIAL REGISTRATION NUMBER NCT04157790.
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Affiliation(s)
- Thomas Moumneh
- Département de Médecine d'Urgence, CHU d'Angers, Angers, France
- Institut MitoVasc, UMR CNRS 6215 INSERM 1083, Université d'Angers, Angers, France
| | - Andrea Penaloza
- Service de Médecine d'Urgence, Cliniques Universitaires St-Luc, Brussels, Belgium
| | - Sandrine Charpentier
- Département de médecine d'Urgence, Hopital Purpan - CHU de Toulouse, Toulouse, France
- Laboratoire d'épidemiologie et d'analyse en santé publique, UMR 1027 INSERM, F-31000, Toulouse III - Paul Sabatier University, Toulouse, France
| | - Delphine Douillet
- Département de Médecine d'Urgence, CHU d'Angers, Angers, France
- Institut MitoVasc, UMR CNRS 6215 INSERM 1083, Université d'Angers, Angers, France
| | - Fabrice Prunier
- Institut MitoVasc, UMR CNRS 6215 INSERM 1083, Université d'Angers, Angers, France
- Département de Cardiologie, CHU d'Angers, Angers, France
| | - Jérémie Riou
- Département de biostatstiques et de métodologie, CHU d'Angers, Angers, France
- MINT, INSERM UMR 1066, CNRS UMR 6021, Université Angers, Angers, France
| | - Pierre-Marie Roy
- Département de Médecine d'Urgence, CHU d'Angers, Angers, France
- Institut MitoVasc, UMR CNRS 6215 INSERM 1083, Université d'Angers, Angers, France
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22
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Galanaud JP, Genty-Vermorel C, Barrellier MT, Becker F, Jabbour V, Blaise S, Bura-Rivière A, Comte A, Grange C, Guenneguez H, Maufus M, Ouvry P, Richaud C, Rolland C, Schmidt J, Sevestre MA, Verrière F, Bosson JL, Bosson JL, Pichot O, Maufus M, Guenneguez H, Ouvry P, Di Maio A, Schmidt J, Galanaud JP, Bura-Rivière A, Couturaud F, Danguy Des Déserts M, Grange C, Mismetti P, Barrellier MT, Laneelle D, Terriat B, Stansal A, Martin M, Quashie C, Bonaldi M, Lanoye P, Ponchaux-Crépin F, Berremili T, Sevestre-Pietri MA, Samy-Modeliar S, Addala A, Toffin L, Rouquet B, Michot-Casbas M, Lacaze G, Roy PM, Durant C, Baldassini-Esquis AL, Cazanave A, Rouvière D, Skolka H, Salem T, Monsallier JM, Roger B, Tra TQ, Kalolwa M, Diard A, Lambert M, Taiar M, Gaudout C, Ancey S, Jurus C. 25 mm Hg versus 35 mm Hg elastic compression stockings to prevent post-thrombotic syndrome after deep vein thrombosis (CELEST): a randomised, double-blind, non-inferiority trial. Lancet Haematol 2022; 9:e886-e896. [DOI: 10.1016/s2352-3026(22)00247-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/15/2022] [Accepted: 07/18/2022] [Indexed: 11/30/2022]
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23
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Righini M, Robert-Ebadi H, Cremonesi A, Elias A, Sanchez O, Le Moigne E, Schmidt J, Le Gall C, Cornuz J, Aujesky D, Roy PM, Chauleur C, Rouyer F, Poletti PA, Moreau C, Le Gal G. Risk of neonatal hypothyroidism in newborns from mothers exposed to CTPA during pregnancy: Ancillary data from a prospective outcome study. J Thromb Haemost 2022; 20:2550-2555. [PMID: 35950611 DOI: 10.1111/jth.15843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 08/02/2022] [Accepted: 08/03/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Neonatal hypothyroidism is often raised as a potential concern for the use of computed tomography pulmonary angiography (CTPA) in pregnant women with suspected pulmonary embolism (PE). OBJECTIVES To assess the incidence of neonatal hypothyroidism among newborns from mothers exposed to CTPA. PATIENTS/METHODS Pregnant women with clinically suspected PE were included in a multicenter, multinational prospective diagnostic management outcome study, based on pretest clinical probability assessment, high-sensitivity D-dimer testing, bilateral lower limb venous compression ultrasonography, and CTPA. Results of Guthrie tests were systematically collected for newborns of all women who required CTPA as part of the diagnostic strategy. A thyroid-stimulating hormone (TSH) level above 15 U/ml was used to define hypothyroidism. RESULTS Out of the 166 women included in the Swiss participating centers, 149 underwent a CTPA including 14 with twin pregnancies. Eight women suffered a pregnancy loss and results of the Guthrie test could not be retrieved for four newborns. All TSH levels were reported as being below 15 U/ml. The incidence of neonatal hypothyroidism was 0/151 (0.0%, 95% confidence interval: 0.0%-2.5%). CONCLUSIONS We did not identify any cases of neonatal hypothyroidism in our cohort of 149 pregnant women investigated for suspected PE using a CTPA. Along with previous literature data, this provides further reassuring data regarding the use of CTPA in this indication.
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Affiliation(s)
- Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Alessio Cremonesi
- Division of Clinical Biochemistry and Swiss Newborn Screening, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Antoine Elias
- Médecine Vasculaire, Centre Hospitalier de Toulon, Toulon, France
| | - Olivier Sanchez
- Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- INSERM UMR S 1140, Paris, France
- F-CRIN INNOVTE, Saint-Etienne, France
| | | | - Jeannot Schmidt
- Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Jacques Cornuz
- Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Pierre-Marie Roy
- Department of Emergency Medicine, University Hospital of Angers, Angers, France
| | - Céline Chauleur
- INSERM U1059, Saint-Etienne, France
- University of Lyon, Saint-Etienne, France
- Department of Gynecology and Obstetrics, University Hospital, Saint-Etienne, France
| | - Frédéric Rouyer
- Division of Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | | | | | - Grégoire Le Gal
- EA3878 GETBO, Université de Brest, Brest, France
- Department of Hematology, Ottawa Health Research Institute, Ottawa, Ontario, Canada
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24
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Bannelier H, Gorlicki J, Penaloza A, Douillet D, Roy PM, Freund Y, Roussel M. Evaluation of the "hemoptysis" item in clinical decision rules for the diagnosis of pulmonary embolism in the emergency department. Acad Emerg Med 2022; 29:1205-1212. [PMID: 35975482 DOI: 10.1111/acem.14574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/31/2022] [Accepted: 07/12/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Hemoptysis is not common in pulmonary embolism (PE) and lacks specificity for its diagnosis. However, this item is present in different validated scores that estimate the clinical probability of PE. The relevance of this item in clinical decision rules (CDRs) is not clearly established. OBJECTIVE The aim of this study was to evaluate the impact of removing the "hemoptysis" item from the PERC, YEARS, and PEGeD CDR in patients with low clinical probability of PE. DESIGN This was a post hoc analysis of two European prospective cohorts, which included 2968 patients presenting to the ED with a low clinical probability of PE (PROPER and PERCEPIC) and a 3-month follow-up. The primary endpoint was the false-negative rate of a CDR score without the hemoptysis item. Secondary endpoints included the potential reduction of chest imaging if the item hemoptysis was to be removed and risk stratification of the Geneva and Wells scores without the hemoptysis item. RESULTS Of 2968 patients included (mean ± SD age 46 ± 18 years, 53% female), 87 patients (3%) had a PE diagnosed at 3 months. A total of 2908 were followed-up at 3 months and analyzed. Using the PERC rule with and without the hemoptysis item, there were 13 and 14 missed cases of PE, respectively (failure rate 0.45% [95% CI 0.25%-0.78%] and 0.48% [95% CI 0.27%-0.82%]). Using the YEARS strategy, there were 11 missed PE cases with or without the hemoptysis item (false-negative rate 0.57% [95% CI 0.30%-1.05%]). With the PERC and YEARS rule, removing the hemoptysis item would have led to a 1% reduction in chest imaging. The PEGeD strategy was not modified by the removal of the hemoptysis item. CONCLUSIONS The hemoptysis item could be safely removed from the PERC, YEARS, and PEGeD CDRs. However, there was no subsequent clinically relevant reduction of chest imaging.
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Affiliation(s)
- Héloïse Bannelier
- Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Judith Gorlicki
- Emergency Department, Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris, INSERM U942-MASCOT, Bobigny, France
| | - Andrea Penaloza
- Emergency Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Bruxelles, Belgium
| | - Delphine Douillet
- Emergency Department, Angers University Hospital, Angers, France.,FCRIN, INNOVTE, Saint Etienne, France
| | - Pierre-Marie Roy
- Emergency Department, Angers University Hospital, Angers, France.,FCRIN, INNOVTE, Saint Etienne, France
| | - Yonathan Freund
- Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Université, Improving Emergency Care FHU, Paris, France
| | - Melanie Roussel
- Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Université, Improving Emergency Care FHU, Paris, France
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25
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Stals MAM, Takada T, Kraaijpoel N, van Es N, Büller HR, Courtney DM, Freund Y, Galipienzo J, Le Gal G, Ghanima W, Huisman MV, Kline JA, Moons KGM, Parpia S, Perrier A, Righini M, Robert-Ebadi H, Roy PM, van Smeden M, Wells PS, de Wit K, Geersing GJ, Klok FA. Safety and Efficiency of Diagnostic Strategies for Ruling Out Pulmonary Embolism in Clinically Relevant Patient Subgroups : A Systematic Review and Individual-Patient Data Meta-analysis. Ann Intern Med 2022; 175:244-255. [PMID: 34904857 DOI: 10.7326/m21-2625] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND How diagnostic strategies for suspected pulmonary embolism (PE) perform in relevant patient subgroups defined by sex, age, cancer, and previous venous thromboembolism (VTE) is unknown. PURPOSE To evaluate the safety and efficiency of the Wells and revised Geneva scores combined with fixed and adapted D-dimer thresholds, as well as the YEARS algorithm, for ruling out acute PE in these subgroups. DATA SOURCES MEDLINE from 1 January 1995 until 1 January 2021. STUDY SELECTION 16 studies assessing at least 1 diagnostic strategy. DATA EXTRACTION Individual-patient data from 20 553 patients. DATA SYNTHESIS Safety was defined as the diagnostic failure rate (the predicted 3-month VTE incidence after exclusion of PE without imaging at baseline). Efficiency was defined as the proportion of individuals classified by the strategy as "PE considered excluded" without imaging tests. Across all strategies, efficiency was highest in patients younger than 40 years (47% to 68%) and lowest in patients aged 80 years or older (6.0% to 23%) or patients with cancer (9.6% to 26%). However, efficiency improved considerably in these subgroups when pretest probability-dependent D-dimer thresholds were applied. Predicted failure rates were highest for strategies with adapted D-dimer thresholds, with failure rates varying between 2% and 4% in the predefined patient subgroups. LIMITATIONS Between-study differences in scoring predictor items and D-dimer assays, as well as the presence of differential verification bias, in particular for classifying fatal events and subsegmental PE cases, all of which may have led to an overestimation of the predicted failure rates of adapted D-dimer thresholds. CONCLUSION Overall, all strategies showed acceptable safety, with pretest probability-dependent D-dimer thresholds having not only the highest efficiency but also the highest predicted failure rate. From an efficiency perspective, this individual-patient data meta-analysis supports application of adapted D-dimer thresholds. PRIMARY FUNDING SOURCE Dutch Research Council. (PROSPERO: CRD42018089366).
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Affiliation(s)
- Milou A M Stals
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands (M.A.M.S., M.V.H., F.A.K.)
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands, and Department of General Medicine, Shirakawa Satellite for Teaching and Research (STAR), Fukushima Medical University, Fukushima, Japan (T.T.)
| | - Noémie Kraaijpoel
- Department of Vascular Medicine, Amsterdam University Medical Center, location AMC, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands (N.K., N.v.E., H.R.B.)
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam University Medical Center, location AMC, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands (N.K., N.v.E., H.R.B.)
| | - Harry R Büller
- Department of Vascular Medicine, Amsterdam University Medical Center, location AMC, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands (N.K., N.v.E., H.R.B.)
| | - D Mark Courtney
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas (D.M.C.)
| | - Yonathan Freund
- Department of Emergency Medicine, Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France (Y.F.)
| | - Javier Galipienzo
- Service of Anesthesiology, Hospital MD Anderson Cancer Center, Madrid, Spain (J.G.)
| | - Grégoire Le Gal
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Thrombosis Research Group, Ottawa, Ontario, Canada (G.L.G., P.S.W.)
| | - Waleed Ghanima
- Department of Medicine, Østfold Hospital Trust and Institute of Clinical Medicine, University of Oslo, Oslo, Norway (W.G.)
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands (M.A.M.S., M.V.H., F.A.K.)
| | - Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana (J.A.K.)
| | - Karel G M Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (K.G.M.M., M.v.S., G.J.G.)
| | - Sameer Parpia
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada (S.P.)
| | - Arnaud Perrier
- Division of Angiology and Hemostasis, Department of Medical Specialties, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland (A.P., M.R., H.R.E.)
| | - Marc Righini
- Division of Angiology and Hemostasis, Department of Medical Specialties, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland (A.P., M.R., H.R.E.)
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Department of Medical Specialties, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland (A.P., M.R., H.R.E.)
| | - Pierre-Marie Roy
- Department of Emergency Medicine, University of Angers, Angers, France (P.M.R.)
| | - Maarten van Smeden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (K.G.M.M., M.v.S., G.J.G.)
| | - Phil S Wells
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Thrombosis Research Group, Ottawa, Ontario, Canada (G.L.G., P.S.W.)
| | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University, Kingston, and Departments of Medicine and Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada (K.d.W.)
| | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (K.G.M.M., M.v.S., G.J.G.)
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands (M.A.M.S., M.V.H., F.A.K.)
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Douillet D, Dupont C, Leloup N, Ménager G, Delori M, Soulie C, Morin F, Moumneh T, Savary D, Roy PM, Armand A. Prevalence and characterization of forgoing care: comparison of two prospective multicentre cohorts between pre-COVID-19 era and a lockdown period. Arch Public Health 2022; 80:32. [PMID: 35042548 PMCID: PMC8766360 DOI: 10.1186/s13690-022-00797-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 01/07/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Little is known about patients who forego healthcare, although it is an important provider of unfavorable health-related outcomes. Forgoing healthcare characterizes situations in which people do not initiate or interrupt a care process, even though they perceive the need for it, whether or not this need is medically proven. The aims of this study were to assess the prevalence and the determinants of patients who forego healthcare. The second aim was to compare the characteristics of patients who gave up healthcare during the French lockdown due to COVID-19. METHODS We conducted two multicenter cross-sectional studies in 2017 and 2020 carried out in French patients presenting to the emergency departments. Patients who gave their consent to participate were interviewed with a standardized questionnaire. It consisted of two parts: epidemiological characteristics and health care refusal. A third part concerning the renunciation of care during the COVID-19 period was added to the second study period. RESULTS A total of 1878 patients had completed the questionnaire during the interview with the physicians, 900 during the first period in 2017 (47.9%) and 978 (52.1%) during the second period. A total of 401/1878 patients reported not seeking care in the last 12 months (21.4% [95%CI: 19.5-23.3%]). In 2020, patients forewent care more during the confinement period than outside with different characteristics of the foregoing care populations. CONCLUSION Forgoing care is common in a universal health care system such as France's and increased during the pandemic. Key public health messages targeted at the reasons for not seeking care must now be disseminated in order to combat this.
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Affiliation(s)
- Delphine Douillet
- Emergency Department, Angers University Hospital, UNIV Angers, Angers, France. .,UMR MitoVasc CNRS 6015 - INSERM 1083, Health Faculty, Angers, France.
| | - Clémence Dupont
- Emergency Department, Angers University Hospital, UNIV Angers, Angers, France
| | - Noémie Leloup
- Emergency Department, Le Mans Hospital, Le Mans, France
| | | | - Maud Delori
- Emergency Department, Angers University Hospital, UNIV Angers, Angers, France
| | | | - François Morin
- Emergency Department, Angers University Hospital, UNIV Angers, Angers, France
| | - Thomas Moumneh
- Emergency Department, Angers University Hospital, UNIV Angers, Angers, France.,UMR MitoVasc CNRS 6015 - INSERM 1083, Health Faculty, Angers, France
| | - Dominique Savary
- Emergency Department, Angers University Hospital, UNIV Angers, Angers, France.,EHESP, Irset, Inserm, UMR S1085, CAPTV CDC, University of Rennes, Rennes, France
| | - Pierre-Marie Roy
- Emergency Department, Angers University Hospital, UNIV Angers, Angers, France.,UMR MitoVasc CNRS 6015 - INSERM 1083, Health Faculty, Angers, France
| | - Aurore Armand
- Emergency Department, Angers University Hospital, UNIV Angers, Angers, France.,République des Savoirs- Lettres, Sciences, Philosophie - USR3608- ED540- ENS-PSL, Paris, France
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27
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Geersing GJ, Takada T, Klok FA, Büller HR, Courtney DM, Freund Y, Galipienzo J, Le Gal G, Ghanima W, Kline JA, Huisman MV, Moons KGM, Perrier A, Parpia S, Robert-Ebadi H, Righini M, Roy PM, van Smeden M, Stals MAM, Wells PS, de Wit K, Kraaijpoel N, van Es N. Ruling out pulmonary embolism across different healthcare settings: A systematic review and individual patient data meta-analysis. PLoS Med 2022; 19:e1003905. [PMID: 35077453 PMCID: PMC8824365 DOI: 10.1371/journal.pmed.1003905] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 02/08/2022] [Accepted: 01/06/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The challenging clinical dilemma of detecting pulmonary embolism (PE) in suspected patients is encountered in a variety of healthcare settings. We hypothesized that the optimal diagnostic approach to detect these patients in terms of safety and efficiency depends on underlying PE prevalence, case mix, and physician experience, overall reflected by the type of setting where patients are initially assessed. The objective of this study was to assess the capability of ruling out PE by available diagnostic strategies across all possible settings. METHODS AND FINDINGS We performed a literature search (MEDLINE) followed by an individual patient data (IPD) meta-analysis (MA; 23 studies), including patients from self-referral emergency care (n = 12,612), primary healthcare clinics (n = 3,174), referred secondary care (n = 17,052), and hospitalized or nursing home patients (n = 2,410). Multilevel logistic regression was performed to evaluate diagnostic performance of the Wells and revised Geneva rules, both using fixed and adapted D-dimer thresholds to age or pretest probability (PTP), for the YEARS algorithm and for the Pulmonary Embolism Rule-out Criteria (PERC). All strategies were tested separately in each healthcare setting. Following studies done in this field, the primary diagnostic metrices estimated from the models were the "failure rate" of each strategy-i.e., the proportion of missed PE among patients categorized as "PE excluded" and "efficiency"-defined as the proportion of patients categorized as "PE excluded" among all patients. In self-referral emergency care, the PERC algorithm excludes PE in 21% of suspected patients at a failure rate of 1.12% (95% confidence interval [CI] 0.74 to 1.70), whereas this increases to 6.01% (4.09 to 8.75) in referred patients to secondary care at an efficiency of 10%. In patients from primary healthcare and those referred to secondary care, strategies adjusting D-dimer to PTP are the most efficient (range: 43% to 62%) at a failure rate ranging between 0.25% and 3.06%, with higher failure rates observed in patients referred to secondary care. For this latter setting, strategies adjusting D-dimer to age are associated with a lower failure rate ranging between 0.65% and 0.81%, yet are also less efficient (range: 33% and 35%). For all strategies, failure rates are highest in hospitalized or nursing home patients, ranging between 1.68% and 5.13%, at an efficiency ranging between 15% and 30%. The main limitation of the primary analyses was that the diagnostic performance of each strategy was compared in different sets of studies since the availability of items used in each diagnostic strategy differed across included studies; however, sensitivity analyses suggested that the findings were robust. CONCLUSIONS The capability of safely and efficiently ruling out PE of available diagnostic strategies differs for different healthcare settings. The findings of this IPD MA help in determining the optimum diagnostic strategies for ruling out PE per healthcare setting, balancing the trade-off between failure rate and efficiency of each strategy.
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Affiliation(s)
- Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- * E-mail:
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima Medical University, Fukushima, Japan
| | - Frederikus A. Klok
- Department of Medicine, Thrombosis and Haemostasis, Dutch Thrombosis Network, Leiden University Medical Center, Leiden, the Netherlands
| | - Harry R. Büller
- Department of Medicine, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - D. Mark Courtney
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Yonathan Freund
- Sorbonne University, Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique—Hôpitaux de Paris, Paris, France
| | - Javier Galipienzo
- Service of Anesthesiology, MD Anderson Cancer Center Madrid, Madrid, Spain
| | - Gregoire Le Gal
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Waleed Ghanima
- Department of Medicine, Østfold Hospital Trust, Norway and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jeffrey A. Kline
- Department of Emergency Medicine, Wayne State School of Medicine, Detroit, Michigan, United States of America
| | - Menno V. Huisman
- Department of Medicine, Thrombosis and Haemostasis, Dutch Thrombosis Network, Leiden University Medical Center, Leiden, the Netherlands
| | - Karel G. M. Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Cochrane Netherlands, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Arnaud Perrier
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Sameer Parpia
- Department of Oncology, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Pierre-Marie Roy
- UNIV Angers, UMR (CNRS 6015—INSERM 1083) and CHU Angers, Department of Emergency Medicine, F-CRIN InnoVTE, Angers, France
| | - Maarten van Smeden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Milou A. M. Stals
- Department of Medicine, Thrombosis and Haemostasis, Dutch Thrombosis Network, Leiden University Medical Center, Leiden, the Netherlands
| | - Philip S. Wells
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Kerstin de Wit
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Department of Emergency Medicine, Queen’s University, Kingston, Canada
| | - Noémie Kraaijpoel
- Department of Medicine, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Nick van Es
- Department of Medicine, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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Le Gal G, Kovacs MJ, Bertoletti L, Couturaud F, Dennie C, Hirsch AM, Huisman MV, Klok FA, Kraaijpoel N, Mallick R, Pecarskie A, Pena E, Phillips P, Pichon I, Ramsay T, Righini M, Rodger MA, Roy PM, Sanchez O, Schmidt J, Schulman S, Shivakumar S, Trinh-Duc A, Verdet R, Vinsonneau U, Wells P, Wu C, Yeo E, Carrier M. Risk for Recurrent Venous Thromboembolism in Patients With Subsegmental Pulmonary Embolism Managed Without Anticoagulation : A Multicenter Prospective Cohort Study. Ann Intern Med 2022; 175:29-35. [PMID: 34807722 DOI: 10.7326/m21-2981] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The incidence of pulmonary embolism has been increasing, but its case-fatality rate is decreasing, suggesting a lesser severity of illness. The clinical importance of patients with pulmonary embolism isolated to the subsegmental vessels is unknown. OBJECTIVE To determine the rate of recurrent venous thromboembolism in patients with subsegmental pulmonary embolism managed without anticoagulation. DESIGN Multicenter prospective cohort study. (ClinicalTrials.gov: NCT01455818). SETTING Eighteen sites between February 2011 and February 2021. PATIENTS Patients with isolated subsegmental pulmonary embolism. INTERVENTION At diagnosis, patients underwent bilateral lower-extremity venous ultrasonography, which was repeated 1 week later if results were negative. Patients without deep venous thrombosis did not receive anticoagulant therapy. MEASUREMENTS The primary outcome was recurrent venous thromboembolism during the 90-day follow-up period. RESULTS Recruitment was stopped prematurely because the predefined stopping rule was met after 292 of a projected 300 patients were enrolled. Of the 266 patients included in the primary analysis, the primary outcome occurred in 8 patients, for a cumulative incidence of 3.1% (95% CI, 1.6% to 6.1%) over the 90-day follow-up. The incidence of recurrent venous thromboembolism was 2.1% (CI, 0.8% to 5.5%) and 5.7% (CI, 2.2% to 14.4%) over the 90-day follow-up in patients with single and multiple isolated subsegmental pulmonary embolism, respectively. No patients had a fatal recurrent pulmonary embolism. LIMITATION The study was restricted to patients with low-risk subsegmental pulmonary embolism. CONCLUSION Overall, patients with subsegmental pulmonary embolism who did not have proximal deep venous thrombosis had a higher-than-expected rate of recurrent venous thromboembolism. PRIMARY FUNDING SOURCE Heart and Stroke Foundation of Canada and French Ministry of Health Programme Hospitalier de Recherche Clinique.
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Affiliation(s)
- Grégoire Le Gal
- Centre d'Investigation Clinique, Centre Hospitalier Régional et Universitaire de Brest, Brest, France, and Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (G.L.)
| | - Michael J Kovacs
- Division of Hematology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada (M.J.K.)
| | - Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, Hôpital Nord, CHU de St-Etienne, INSERM, SAINBIOSE, U1059, Dysfonction Vasculaire et Hémostase et Université Jean-Monnet, CIC1408, F- 42055 Saint-Etienne, Réseau français F-CRIN INNOVTE, Saint-Etienne, France (L.B.)
| | - Francis Couturaud
- Centre d'Investigation Clinique, Centre Hospitalier Régional et Universitaire de Brest, and Département de médecine interne, médecine vasculaire et pneumologie, Hôpital de la Cavale Blanche, EA3878-GETBO, Univ Brest, Réseau français F-CRIN INNOVTE, CHRU Brest, Brest, France (F.C.)
| | - Carole Dennie
- Department of Radiology, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (C.D., E.P.)
| | - Andrew M Hirsch
- Department of Medicine, McGill University, Jewish General Hospital, Montreal, Quebec, Canada (A.M.H.)
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Dutch Thrombosis Network, Leiden, the Netherlands (M.V.H., F.A.K.)
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Dutch Thrombosis Network, Leiden, the Netherlands (M.V.H., F.A.K.)
| | - Noémie Kraaijpoel
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands (N.K.)
| | - Ranjeeta Mallick
- Ottawa Methods Center, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (R.M.)
| | - Amanda Pecarskie
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (A.P., P.P., P.W., M.C.)
| | - Elena Pena
- Department of Radiology, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (C.D., E.P.)
| | - Penny Phillips
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (A.P., P.P., P.W., M.C.)
| | - Isabelle Pichon
- Service de Recherche Clinique, Hôpital d'Instruction des Armées, Brest, France (I.P.)
| | - Tim Ramsay
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (T.R.)
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland (M.R.)
| | - Marc A Rodger
- Department of Medicine, McGill University, McGill University Health Center, Montreal, Quebec, Canada (M.A.R.)
| | - Pierre-Marie Roy
- Univ Angers, MITOVASC, Equipe CarMe, Département de Médecine d'Urgence, Centre Hospitalier Universitaire d'Angers, Réseau français F-CRIN INNOVTE, Angers, France (P.R.)
| | - Olivier Sanchez
- Université de Paris, Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP.Centre - Université de Paris, INSERM UMR S 1140 Innovative therapies in hemostasis, Réseau français F-CRIN INNOVTE, Paris, France (O.S.)
| | - Jeannot Schmidt
- Département de Médecine d'Urgence, Centre Hospitalier Universitaire Gabriel Montpied, Réseau français F-CRIN INNOVTE, Clermont-Ferrand, France (J.S.)
| | - Sam Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada, and Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia (S.S.)
| | - Sudeep Shivakumar
- Department of Medicine, Dalhousie University, Nova Scotia Health, Halifax, Nova Scotia, Canada (S.S.)
| | | | - Rachel Verdet
- Direction de la Recherche et de l'Innovation, Centre Hospitalier Régional Universitaire de Brest, Brest, France (R.V.)
| | - Ulric Vinsonneau
- Department of Cardiology, Clermont Tonnerre Hospital of Military Training, Brest, France (U.V.)
| | - Philip Wells
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (A.P., P.P., P.W., M.C.)
| | - Cynthia Wu
- Department of Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada (C.W.)
| | - Erik Yeo
- Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada (E.Y.)
| | - Marc Carrier
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (A.P., P.P., P.W., M.C.)
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Moumneh T, Douillet D, Savary D, Roy PM. Do Not Throw Out the Baby With the Bathwater. Ann Emerg Med 2021; 79:85-86. [PMID: 34949412 DOI: 10.1016/j.annemergmed.2021.09.429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Thomas Moumneh
- Département de Médecine d'Urgence, Centre hospitalier universitaire d'Angers, Angers, France; Institut MITOVASC, Centre National de Recherche Scientifique 6015 Institut National de la Santé Et de la Recherche Médicale 1083, Université d'Angers, Angers, France
| | - Delphine Douillet
- Département de Médecine d'Urgence, Centre hospitalier universitaire d'Angers, Angers, France; Institut MITOVASC, Centre National de Recherche Scientifique 6015 Institut National de la Santé Et de la Recherche Médicale 1083, Université d'Angers, Angers, France
| | - Dominique Savary
- Département de Médecine d'Urgence, Centre hospitalier universitaire d'Angers, Angers, France; Ecole des Hautes Etudes en Santé Publique, Institut de Recherche en Santé Environnement et Travail, Institut National de la Santé Et de la Recherche Médicale S1085, Université de Rennes, Angers, France
| | - Pierre-Marie Roy
- Département de Médecine d'Urgence, Centre hospitalier universitaire d'Angers, Angers, France; Institut MITOVASC, Centre National de Recherche Scientifique 6015 Institut National de la Santé Et de la Recherche Médicale 1083, Université d'Angers, Angers, France
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Douillet D, Riou J, Penaloza A, Moumneh T, Soulie C, Savary D, Morin F, Mahieu R, Roy PM. Risk of symptomatic venous thromboembolism in mild and moderate COVID-19: A comparison of two prospective European cohorts. Thromb Res 2021; 208:4-10. [PMID: 34653718 PMCID: PMC8498792 DOI: 10.1016/j.thromres.2021.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/30/2021] [Accepted: 10/03/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Severely ill patients with SARS-CoV-2 have an increased risk of venous thromboembolism (VTE) i.e., deep vein thrombosis and pulmonary embolism. However, the VTE risk in patients with mild and moderate COVID-19, hospitalized or managed at home, remain uncertain. The aims of this study were to assess the rate and the risk factors symptomatic VTE, in patients with mild and moderate COVID-19 and to compare them to a cohort of similar patients without COVID-19. METHODS Patients presenting to the emergency department (ED) of participating centers for confirmed or probable mild or moderate COVID-19 and not having acute VTE were included. This COVID-19 cohort was retrospectively compared to a prospective cohort of similar ED patients using propensity score matching. The main outcome was the rate of symptomatic VTE within the 28 days after ED presentation. RESULTS A total of 2292 patients were included in the COVID-19 cohort. The 28-day incidence of symptomatic VTE was 1.3% (n = 29/2292, 95%CI: 0.9 to 1.8), 2.3% (n = 20/866, 95%CI: 1.5 to 3.5) in moderate COVID-19 patients and 0.6% (n = 9/1426; 95%CI: 0.3 to 1.2) in mild COVID-19 patients managed as outpatients. An age over 65 years and hospitalization were independent risk factors of VTE. After adjustment, patients in the COVID-19 cohort had an absolute increase in over symptomatic VTE risk of +1.69% (95%CI, 0.88 to 2.51) versus patients in the comparison cohort (n = 1539). CONCLUSIONS Patients with moderate COVID-19 presenting to the ED had a high risk of subsequent VTE. TRIAL REGISTRATION Ethics committee of the CHU of Angers (N°2020/87).
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Affiliation(s)
- Delphine Douillet
- Emergency Department, Angers University Hospital, Angers, France,UNIV Angers, UMR MitoVasc CNRS 6015 - INSERM 1083, Angers, France,FCRIN, INNOVTE, Saint Etienne, France,Corresponding author at: Département de Médecine d'Urgence, Centre Hospitalier Universitaire d'Angers, 4 rue Larrey, 49100 Angers, France
| | - Jérémie Riou
- UNIV Angers, UMR MINT, INSERM 1066 - CNRS 6021, Angers, France,Methodology and Biostatistics Department, Delegation to Clinical Research and Innovation, Angers University Hospital, Angers, France
| | - Andrea Penaloza
- FCRIN, INNOVTE, Saint Etienne, France,Emergency Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Bruxelles, Belgium
| | - Thomas Moumneh
- Emergency Department, Angers University Hospital, Angers, France,UNIV Angers, UMR MitoVasc CNRS 6015 - INSERM 1083, Angers, France,FCRIN, INNOVTE, Saint Etienne, France
| | | | - Dominique Savary
- Emergency Department, Angers University Hospital, Angers, France,EHESP, Irset, UMR INSERM S1085, CAPTV CDC, University of Rennes, Rennes, France
| | - Francois Morin
- Emergency Department, Angers University Hospital, Angers, France
| | - Rafaël Mahieu
- Department of Infectious Diseases, Angers University Hospital, Angers, France,UNIV Angers, UMR CRCINA, INSERM 1232, SFR ICAT, Angers, France
| | - Pierre-Marie Roy
- Emergency Department, Angers University Hospital, Angers, France,UNIV Angers, UMR MitoVasc CNRS 6015 - INSERM 1083, Angers, France,FCRIN, INNOVTE, Saint Etienne, France
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Roy PM, Moumneh T, Penaloza A. Safety of the 4PEPS in Patients With a Very Low Prevalence of Pulmonary Embolism-Need for More Than a Point Estimate-Reply. JAMA Cardiol 2021; 6:1468-1469. [PMID: 34643652 DOI: 10.1001/jamacardio.2021.4011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Pierre-Marie Roy
- Emergency Department, CHU Angers, Angers, France.,UNIV Angers, Health Faculty, UMR MitoVasc CNRS 6015 - INSERM 1083, Equipe CARME, Angers, France.,F-CRIN INNOVTE, Saint-Etienne, France
| | - Thomas Moumneh
- Emergency Department, CHU Angers, Angers, France.,UNIV Angers, Health Faculty, UMR MitoVasc CNRS 6015 - INSERM 1083, Equipe CARME, Angers, France.,F-CRIN INNOVTE, Saint-Etienne, France
| | - Andrea Penaloza
- F-CRIN INNOVTE, Saint-Etienne, France.,Emergency Department, Cliniques universitaires Saint Luc, Brussels, Belgium.,UCLouvain, Brussels, Belgium
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Roy PM, Penaloza A, Hugli O, Klok FA, Arnoux A, Elias A, Couturaud F, Joly LM, Lopez R, Faber LM, Daoud-Elias M, Planquette B, Bokobza J, Viglino D, Schmidt J, Juchet H, Mahe I, Mulder F, Bartiaux M, Cren R, Moumneh T, Quere I, Falvo N, Montaclair K, Douillet D, Steinier C, Hendriks SV, Benhamou Y, Szwebel TA, Pernod G, Dublanchet N, Lapebie FX, Javaud N, Ghuysen A, Sebbane M, Chatellier G, Meyer G, Jimenez D, Huisman MV, Sanchez O. Triaging acute pulmonary embolism for home treatment by Hestia or simplified PESI criteria: the HOME-PE randomized trial. Eur Heart J 2021; 42:3146-3157. [PMID: 34363386 PMCID: PMC8408662 DOI: 10.1093/eurheartj/ehab373] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 02/02/2021] [Accepted: 06/02/2021] [Indexed: 12/13/2022] Open
Abstract
AIMS The aim of this study is to compare the Hestia rule vs. the simplified Pulmonary Embolism Severity Index (sPESI) for triaging patients with acute pulmonary embolism (PE) for home treatment. METHODS AND RESULTS Normotensive patients with PE of 26 hospitals from France, Belgium, the Netherlands, and Switzerland were randomized to either triaging with Hestia or sPESI. They were designated for home treatment if the triaging tool was negative and if the physician-in-charge, taking into account the patient's opinion, did not consider that hospitalization was required. The main outcomes were the 30-day composite of recurrent venous thrombo-embolism, major bleeding or all-cause death (non-inferiority analysis with 2.5% absolute risk difference as margin), and the rate of patients discharged home within 24 h after randomization (NCT02811237). From January 2017 through July 2019, 1975 patients were included. In the per-protocol population, the primary outcome occurred in 3.82% (34/891) in the Hestia arm and 3.57% (32/896) in the sPESI arm (P = 0.004 for non-inferiority). In the intention-to-treat population, 38.4% of the Hestia patients (378/984) were treated at home vs. 36.6% (361/986) of the sPESI patients (P = 0.41 for superiority), with a 30-day composite outcome rate of 1.33% (5/375) and 1.11% (4/359), respectively. No recurrent or fatal PE occurred in either home treatment arm. CONCLUSIONS For triaging PE patients, the strategy based on the Hestia rule and the strategy based on sPESI had similar safety and effectiveness. With either tool complemented by the overruling of the physician-in-charge, more than a third of patients were treated at home with a low incidence of complications.
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Affiliation(s)
- Pierre-Marie Roy
- Emergency Department, CHU Angers, 4 rue Larrey, Angers, France, F-49000.,Univ. Angers, INSERM, CNRS, MITOVASC, Equipe CARME, SFR ICAT, Angers, France.,F-CRIN, INNOVTE, Saint-Etienne, France
| | - Andrea Penaloza
- F-CRIN, INNOVTE, Saint-Etienne, France.,Emergency Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium.,UCLouvain, Brussels, Belgium
| | - Olivier Hugli
- Emergency Department, University Hospital of Lausanne, Lausanne, Switzerland
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, DTN, Leiden University Medical Center, Leiden, the Netherlands
| | - Armelle Arnoux
- Computing, Statistics and Public Health & CIC1418, Hôpital Européen Georges Pompidou, APHP, Paris, France.,University of Paris, Paris, France
| | - Antoine Elias
- F-CRIN, INNOVTE, Saint-Etienne, France.,Department of Cardiology and Vascular Medicine, CH Sainte Musse - Toulon, Toulon, France
| | - Francis Couturaud
- F-CRIN, INNOVTE, Saint-Etienne, France.,Department of Internal Medicine and Chest Disease, CHU Brest, Brest, France.,EA3878-GETBO, CIC-INSERM1412, Univ-Brest, Brest, France
| | - Luc-Marie Joly
- Emergency Department, CHU Rouen, Normandy Univ, UNIROUEN, Rouen, France
| | - Raphaëlle Lopez
- Emergency Department, Sart Tilman University Hospital, Liège, Belgium
| | - Laura M Faber
- Department of Internal Medicine, Rode Kruis Hospital, Beverwijk, DTN, the Netherlands
| | - Marie Daoud-Elias
- Department of Cardiology and Vascular Medicine, CH Sainte Musse - Toulon, Toulon, France
| | - Benjamin Planquette
- F-CRIN, INNOVTE, Saint-Etienne, France.,Department of Pneumology and Intensive Care, Hôpital Europeen Georges Pompidou, APHP, Paris, France.,University of Paris, INSERM UMR-S 1140 Innovaties Therapies in Haemostasis, Paris, France
| | - Jérôme Bokobza
- Emergency Department, Hôpital Cochin, APHP, Paris, France
| | - Damien Viglino
- Emergency Department, CHU Grenoble Alpes, Grenoble, France.,HP2 INSERM U 1042 Laboratory, University of Grenoble-Alpes, Grenoble, France
| | - Jeannot Schmidt
- F-CRIN, INNOVTE, Saint-Etienne, France.,Emergency Department, CHU Clermont-Ferrand, University of Clermont Auvergne, Clermont-Ferrand, France
| | - Henry Juchet
- Emergency Department, CHU Toulouse, Toulouse, France
| | - Isabelle Mahe
- F-CRIN, INNOVTE, Saint-Etienne, France.,Internal Medicine Department, HU Paris Nord, Louis Mourier Hospital, APHP, Colombes, France.,Inserm UMR_S1140 Hemostasis Therapeutical Innovations, University of Paris, Colombes, France
| | - Frits Mulder
- Department of Internal Medicine, Tergooi Hospital, Hilversum, the Netherlands
| | - Magali Bartiaux
- Emergency Department, Saint-Pierre Hospital, Brussels, Belgium
| | - Rosen Cren
- Emergency Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Thomas Moumneh
- Emergency Department, CHU Angers, 4 rue Larrey, Angers, France, F-49000.,Univ. Angers, INSERM, CNRS, MITOVASC, Equipe CARME, SFR ICAT, Angers, France.,F-CRIN, INNOVTE, Saint-Etienne, France
| | - Isabelle Quere
- F-CRIN, INNOVTE, Saint-Etienne, France.,Vascular Medicine Department, CHU Montpellier, EA2992, CIC 1001, University of Montpellier, Montpellier, France
| | - Nicolas Falvo
- Vascular Medicine Department, CHU Dijon, Dijon, France
| | - Karine Montaclair
- F-CRIN, INNOVTE, Saint-Etienne, France.,Department of Cardiology, CH Le Mans, Le Mans, France
| | - Delphine Douillet
- Emergency Department, CHU Angers, 4 rue Larrey, Angers, France, F-49000.,Univ. Angers, INSERM, CNRS, MITOVASC, Equipe CARME, SFR ICAT, Angers, France.,F-CRIN, INNOVTE, Saint-Etienne, France
| | - Charlotte Steinier
- Emergency Department, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Stephan V Hendriks
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Ygal Benhamou
- Department of Internal Medicine, CHU Charles Nicolle, Rouen, France.,Normandie University, UNIROUEN, INSERM U1096 EnVI, Rouen, France
| | - Tali-Anne Szwebel
- Department of Internal Medicine, Cochin Hospital, APHP, Paris, France
| | - Gilles Pernod
- F-CRIN, INNOVTE, Saint-Etienne, France.,Department of Vascular Medicine, CHU Grenoble Alpes, Grenoble, France.,University Grenoble Alpes, CNRS / TIMC-IMAG UMR 5525 / Themas, Grenoble, France
| | - Nicolas Dublanchet
- Emergency Department, CHU Clermont-Ferrand, University of Clermont Auvergne, Clermont-Ferrand, France
| | | | - Nicolas Javaud
- Emergency Department, CréAk, Louis Mourier Hospital, APHP, University of Paris, Colombes, France
| | - Alexandre Ghuysen
- Emergency Department, Sart Tilman University Hospital, Liège, Belgium
| | - Mustapha Sebbane
- F-CRIN, INNOVTE, Saint-Etienne, France.,Emergency Department, Lapeyronie Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Gilles Chatellier
- Computing, Statistics and Public Health & CIC1418, Hôpital Européen Georges Pompidou, APHP, Paris, France.,University of Paris, Paris, France
| | - Guy Meyer
- Department of Pneumology and Intensive Care, Hôpital Europeen Georges Pompidou, APHP, Paris, France.,University of Paris, INSERM UMR-S 1140 Innovaties Therapies in Haemostasis, Paris, France
| | - David Jimenez
- Respiratory Department and Medicine Department, Ramon y Cajal Hospital IRYCIS Alcal de Henares University, Madrid, Spain
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Olivier Sanchez
- F-CRIN, INNOVTE, Saint-Etienne, France.,University of Paris, INSERM UMR-S 1140 Innovaties Therapies in Haemostasis, Paris, France.,Pneumology Department and Intensive Care, Hôpital Européen Georges Pompidou, APHP, 20-40 rue Leblanc, Paris, France, F-75908
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Dubée V, Roy PM, Vielle B, Parot-Schinkel E, Blanchet O, Darsonval A, Lefeuvre C, Abbara C, Boucher S, Devaud E, Robineau O, Rispal P, Guimard T, d'Anglejean E, Diamantis S, Custaud MA, Pellier I, Mercat A. Hydroxychloroquine in mild-to-moderate coronavirus disease 2019: a placebo-controlled double blind trial. Clin Microbiol Infect 2021; 27:1124-1130. [PMID: 33813110 PMCID: PMC8015393 DOI: 10.1016/j.cmi.2021.03.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/19/2021] [Accepted: 03/21/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To determine whether hydroxychloroquine decreases the risk of adverse outcome in patients with mild to moderate coronavirus disease 2019 (COVID-19) at high risk of worsening. METHODS We conducted a multicentre randomized double-blind placebo-controlled trial evaluating hydroxychloroquine in COVID-19 patients with at least one of the following risk factors for worsening: need for supplemental oxygen, age ≥75 years, age between 60 and 74 years and presence of at least one co-morbidity. Severely ill patients requiring oxygen therapy >3 L/min or intensive care were excluded. Eligible patients were randomized in a 1:1 ratio to receive either 800 mg hydroxychloroquine on day 0 followed by 400 mg per day for 8 days or a placebo. The primary end point was a composite of death or start of invasive mechanical ventilation within 14 days following randomization. Secondary end points included mortality and clinical evolution at days 14 and 28, and viral shedding at days 5 and 10. RESULTS The trial was stopped after 250 patients were included because of a slowing down of the pandemic in France. The intention-to-treat population comprised 123 and 124 patients in the placebo and hydroxychloroquine groups, respectively. The median age was 77 years (interquartile range 58-86 years) and 151/250 (60.4%) patients required oxygen therapy. The primary end point occurred in 9/124 (7.3%) patients in the hydroxychloroquine group and 8/123 (6.5%) patients in the placebo group (relative risk 1.12; 95% CI 0.45-2.80). The rates of positive SARS-CoV-2 RT-PCR tests at days 5 and 10 were 72.8% (75/103) and 57.1% (52/91) in the hydroxychloroquine group, versus 73.0% (73/100) and 56.6% (47/83) in the placebo group, respectively. No difference was observed between the two groups in any of the other secondary end points. CONCLUSION In this underpowered trial involving mainly older patients with mild to moderate COVID-19, patients treated with hydroxychloroquine did not experience better clinical or virological outcomes than those receiving the placebo. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04325893 (https://clinicaltrials.gov/ct2/show/NCT04325893).
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Affiliation(s)
- Vincent Dubée
- Service des Maladies Infectieuses et Tropicales, CHU d'Angers, Angers, France; CRCINA, Inserm, Université de Nantes, Université d'Angers, Angers, France.
| | - Pierre-Marie Roy
- Emergency Department, CHU d'Angers, Angers, France; Institut MitoVasc, UMR CNRS 6215 INSERM 1083, Université d'Angers, Angers, France
| | - Bruno Vielle
- Biostatistics and Methodology Department, Maison de La Recherche, CHU d'Angers, Angers, France
| | - Elsa Parot-Schinkel
- Biostatistics and Methodology Department, Maison de La Recherche, CHU d'Angers, Angers, France
| | - Odile Blanchet
- Centre de Ressources Biologiques, BB-0033-00038, CHU d'Angers, Angers, France
| | | | - Caroline Lefeuvre
- Département des Agents Infectieux, Laboratoire de Virologie, CHU Angers, Angers, France
| | - Chadi Abbara
- Laboratoire de Pharmacologie-toxicologie, CHU d'Angers, Angers, France
| | - Sophie Boucher
- Institut MitoVasc, UMR CNRS 6215 INSERM 1083, Université d'Angers, Angers, France; Service d'ORL et Chirurgie Cervico-faciale, CHU d'Angers, Angers, France
| | - Edouard Devaud
- Service de Médecine Interne et Maladies Infectieuses, CH R. Dubos, Pontoise, France
| | - Olivier Robineau
- Service Universitaire des Maladies Infectieuses et du Voyageur, CH de Tourcoing, Tourcoing, France
| | | | - Thomas Guimard
- Service de Médecine Post-urgence, CH Départemental de Vendée, La Roche sur Yon, France
| | - Emma d'Anglejean
- Service de Médecine Interne et Maladies Infectieuses, CH Versailles-Hôpital André Mignot, Le Chesnay, France
| | - Sylvain Diamantis
- Service de Médecine Polyvalente et Maladies Infectieuses, Groupe Hospitalier Sud Ile de France, Melun, France
| | - Marc-Antoine Custaud
- Institut MitoVasc, UMR CNRS 6215 INSERM 1083, Université d'Angers, Angers, France; Centre de Recherche Clinique, CHU d'Angers, Angers, France
| | - Isabelle Pellier
- Unité d'hématologie et d'oncologie Pédiatrique, CHU d'Angers, Inserm U1232-CRCINA, Université d'Angers, Angers, France
| | - Alain Mercat
- Département de Médecine Intensive-Réanimation, CHU d'Angers, Université d'Angers, Angers, France
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Freund Y, Roussel M, Kline J, Roy PM, Bloom B. The failure rate does not equal the false-negative rate: A call for tailoring diagnostic strategy validation in low prevalence populations. J Thromb Haemost 2021; 19:1832-1833. [PMID: 34176222 DOI: 10.1111/jth.15353] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 03/30/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Yonathan Freund
- Sorbonne Université, Paris, France
- Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Mélanie Roussel
- Sorbonne Université, Paris, France
- CHU Charles Nicole, Rouen, France
| | - Jeff Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Pierre-Marie Roy
- Emergency Department, CHU Angers, Institut Mitovasc UMR (CNRS 6015-INSERM 1083), UNIV Angers, F-CRIN INNOVTE, Angers, France
| | - Ben Bloom
- Emergency Department, Barts Health NHS Trust, London, UK
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Roy PM, Douillet D, Penaloza A. Contemporary management of acute pulmonary embolism. Trends Cardiovasc Med 2021; 32:259-268. [PMID: 34214598 DOI: 10.1016/j.tcm.2021.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/17/2021] [Accepted: 06/26/2021] [Indexed: 12/14/2022]
Abstract
This review examines the recent progress in the initial management of pulmonary embolism (PE). Diagnostic strategies allowing the safe decrease of imaging testing have been proposed. New modalities of catheter-based interventions have emerged for hemodynamically unstable PE patients. For normotensive PE patients, direct oral anticoagulant treatment has become the new norm and a large proportion of patients are eligible for home treatment.
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Affiliation(s)
- Pierre-Marie Roy
- Angers University Hospital, Emergency Department; UNIV Angers, Health Faculty, UMR MitoVasc CNRS 6015 - INSERM 1083, Equipe CarMe; F-CRIN INNOVTE; Angers, France.
| | - Delphine Douillet
- Angers University Hospital, Emergency Department; UNIV Angers, Health Faculty, UMR MitoVasc CNRS 6015 - INSERM 1083, Equipe CarMe; F-CRIN INNOVTE; Angers, France
| | - Andrea Penaloza
- Cliniques Universitaires Saint Luc, Emrgency Department; UCLouvain; F-CRIN INNOVTE; Brussels, Belgium.
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Douillet D, Riou J, Thoma M, Moumneh T, Darsonval A, Trinh-Duc A, Hugli O, Chauvin A, Penaloza A, Roy PM. Thromboembolic risk stratification by TRiP(cast) score to rationalise thromboprophylaxis in patients with lower leg trauma requiring immobilisation: a study protocol of the casting stepped-wedge cluster randomised trial. BMJ Open 2021; 11:e045905. [PMID: 34183341 PMCID: PMC8240567 DOI: 10.1136/bmjopen-2020-045905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Patients with lower limb trauma requiring orthopaedic immobilisation may be at risk of venous thromboembolism but opinions differ about who may benefit from thromboprophylactic anticoagulant treatment.The aim of this CASTING study is to demonstrate the safety of thromboprophylaxis based on the Thrombosis Risk Prediction for patients with cast immobilisation (TRiP(cast) score with regards to the 3-month incidence of symptomatic venous thromboembolism events in low-risk patients not receiving thromboprophylaxis, as well as the usefulness of this strategy on the rate of patients receiving anticoagulant treatment in comparison to current practice. METHODS AND ANALYSIS CASTING will be a stepped-wedge cluster randomised controlled clinical trial, performed in 15 emergency departments in France and Belgium. With their informed consent, outpatients admitted to one of the participating emergency departments for a lower limb trauma requiring orthopaedic immobilisation without surgery will be included. All centres will begin the trial with the 'observational period' and, every 2 weeks, 1 centre will be randomly assigned to switch to the 'interventional period' and to apply the TRiP(cast) score, in which only patients with a score ≥7 will receive thromboprophylactic anticoagulant treatment. The primary endpoint is the rate of clinical thromboembolic events within 90 days following the inclusion of low-risk patients not receiving thromboprophylaxis. ETHICS AND DISSEMINATION The protocol has been approved by the Comité de Protection des Personnes Sud I (Ethics Review ID-RCB: 2019-A01829-48) for France and the Comité d'éthique hôpital-facultaire Saint Luc (N° B403201941338) for Belgium. It is carried out in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. The findings of this study will be disseminated in peer-reviewed journals and at scientific conferences. TRIAL REGISTRATION NUMBER NCT04064489.
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Affiliation(s)
- Delphine Douillet
- Emergency Department, University Hospital Centre Angers, Angers, France
- INSERM, CNRS, MITOVASC, Equipe CarMe, SFR ICAT,UNIV Angers, F-CRIN INNOVTE, Angers, France
| | - Jeremie Riou
- Biostatistics and Methodology Department, University Hospital Centre Angers, Angers, France
- MINT, INSERM UMR 1066, CNRS UMR 6021, Faculté de Santé, UNIV Angers, Angers, France
| | - Maximilien Thoma
- Emergency Department, Cliniques universitaires Saint-Luc, Bruxelles, Belgium
| | - Thomas Moumneh
- Emergency Department, University Hospital Centre Angers, Angers, France
- INSERM, CNRS, MITOVASC, Equipe CarMe, SFR ICAT,UNIV Angers, F-CRIN INNOVTE, Angers, France
| | - Astrid Darsonval
- Department of Pharmacy, Angers University Hospital Centre, Angers, France
| | | | - Olivier Hugli
- Emergency Department, University Hospital of Lausanne, Lausanne, Switzerland
| | - Anthony Chauvin
- Emergency Department, Hôpital Lariboisière, Assistance Publique - Hôpitaux de Paris APHP, Université de Paris, Paris, France
| | - Andrea Penaloza
- Emergency Department, Cliniques universitaires Saint-Luc, Bruxelles, Belgium
| | - Pierre-Marie Roy
- Emergency Department, University Hospital Centre Angers, Angers, France
- INSERM, CNRS, MITOVASC, Equipe CarMe, SFR ICAT,UNIV Angers, F-CRIN INNOVTE, Angers, France
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Roy PM, Friou E, Germeau B, Douillet D, Kline JA, Righini M, Le Gal G, Moumneh T, Penaloza A. Derivation and Validation of a 4-Level Clinical Pretest Probability Score for Suspected Pulmonary Embolism to Safely Decrease Imaging Testing. JAMA Cardiol 2021; 6:669-677. [PMID: 33656522 PMCID: PMC7931139 DOI: 10.1001/jamacardio.2021.0064] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance In patients with suspected pulmonary embolism (PE), overuse of diagnostic imaging is an important point of concern. Objective To derive and validate a 4-level pretest probability rule (4-Level Pulmonary Embolism Clinical Probability Score [4PEPS]) that makes it possible to rule out PE solely on clinical criteria and optimized D-dimer measurement to safely decrease imaging testing for suspected PE. Design, Setting, and Participants This study included consecutive outpatients suspected of having PE from US and European emergency departments. Individual data from 3 merged management studies (n = 11 114; overall prevalence of PE, 11%) were used for the derivation cohort and internal validation cohort. The external validation cohorts were taken from 2 independent studies, the first with a high PE prevalence (n = 1548; prevalence, 21.5%) and the second with a moderate PE prevalence (n = 1669; prevalence, 11.7%). A prior definition of pretest probability target values to achieve a posttest probability less than 2% was used on the basis of the negative likelihood ratios of D-dimer. Data were collected from January 2003 to April 2016, and data were analyzed from June 2018 to August 2019. Main Outcomes and Measures The rate of PE diagnosed during the initial workup or during follow-up and the rate of imaging testing. Results Of the 5588 patients in the derivation cohort, 3441 (61.8%) were female, and the mean (SD) age was 52 (18.5) years. The 4PEPS comprises 13 clinical variables scored from -2 to 5. It results in the following strategy: (1) very low probability of PE if 4PEPS is less than 0: PE ruled out without testing; (2) low probability of PE if 4PEPS is 0 to 5: PE ruled out if D-dimer level is less than 1.0 μg/mL; (3) moderate probability of PE if 4PEPS is 6 to 12: PE ruled out if D-dimer level is less than the age-adjusted cutoff value; (4) high probability of PE if 4PEPS is greater than 12: PE ruled out by imaging without preceding D-dimer test. In the first and the second external validation cohorts, the area under the receiver operator characteristic curves were 0.79 (95% CI, 0.76 to 0.82) and 0.78 (95% CI, 0.74 to 0.81), respectively. The false-negative testing rates if the 4PEPS strategy had been applied were 0.71% (95% CI, 0.37 to 1.23) and 0.89% (95% CI, 0.53 to 1.49), respectively. The absolute reductions in imaging testing were -22% (95% CI, -26 to -19) and -19% (95% CI, -22 to -16) in the first and second external validation cohorts, respectively. The 4PEPS strategy compared favorably with all recent strategies in terms of imaging testing. Conclusions and Relevance The 4PEPS strategy may lead to a substantial and safe reduction in imaging testing for patients with suspected PE. It should now be tested in a formal outcome study.
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Affiliation(s)
- Pierre-Marie Roy
- Emergency Department, CHU Angers, Institut Mitovasc UMR (CNRS 6015-INSERM 1083), UNIV Angers, F-CRIN INNOVTE, Angers, France
| | - Emilie Friou
- Emergency Department, CHU Angers, Angers, France
| | - Boris Germeau
- Emergency Department, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Delphine Douillet
- Emergency Department, CHU Angers, Institut Mitovasc UMR (CNRS 6015-INSERM 1083), UNIV Angers, F-CRIN INNOVTE, Angers, France
| | - Jeffrey Allen Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Marc Righini
- Division of Angiology and Hemostasis, Department of Internal Medicine, Faculty of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Grégoire Le Gal
- Ottawa Hospital Research Institute, The Ottawa Hospital, Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Thomas Moumneh
- Emergency Department, CHU Angers, Institut Mitovasc UMR (CNRS 6015-INSERM 1083), UNIV Angers, F-CRIN INNOVTE, Angers, France
| | - Andrea Penaloza
- Emergency Department, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, F-CRIN INNOVTE, Brussels, Belgium
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Robert-Ebadi H, Robin P, Hugli O, Verschuren F, Trinh-Duc A, Roy PM, Schmidt J, Fumeaux T, Meyer G, Hayoz D, Carron PN, Salaun PY, Sarasin F, Rutschmann O, Le Gal G, Righini M. Impact of the Age-Adjusted D-Dimer Cutoff to Exclude Pulmonary Embolism: A Multinational Prospective Real-Life Study (the RELAX-PE Study). Circulation 2021; 143:1828-1830. [PMID: 33939529 DOI: 10.1161/circulationaha.120.052780] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Switzerland (H.R.-E., M.R.)
| | - Philippe Robin
- Service de Médecine Nucléaire, EA 3878 (GETBO), Centre Hospitalier Régional et Universitaire de Brest, Université de Bretagne Occidentale, France (P.R., P.-Y.S.)
| | - Olivier Hugli
- Emergency Department, Lausanne University Hospital and University of Lausanne, Switzerland (O.H., P.-N.C.)
| | - Franck Verschuren
- Department of Acute Medicine, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Institute of Experimental and Clinical Research, Brussels, Belgium (F.V.)
| | | | - Pierre-Marie Roy
- Emergency Department, Centre Hospitalier Universitaire d'Angers, Institut MIOVASC, UMR (CNRS 6015-INSERM 1083), Université d'Angers, France (P.-M.R.)
| | - Jeannot Schmidt
- Centre Hospitalier Universitaire de Clermont- Ferrand, France (J.S.)
| | - Thierry Fumeaux
- Hôpital de Nyon, Groupe Hospitalier de l'Ouest Lémanique, Nyon, Switzerland (T.F.)
| | - Guy Meyer
- Hôpital Européen Georges Pompidou, AP-HP, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S 970, France (G.M.)
| | - Daniel Hayoz
- Hôpital Cantonal de Fribourg, Switzerland (D.H.)
| | - Pierre-Nicolas Carron
- Emergency Department, Lausanne University Hospital and University of Lausanne, Switzerland (O.H., P.-N.C.)
| | - Pierre-Yves Salaun
- Service de Médecine Nucléaire, EA 3878 (GETBO), Centre Hospitalier Régional et Universitaire de Brest, Université de Bretagne Occidentale, France (P.R., P.-Y.S.)
| | - François Sarasin
- Emergency Department, Geneva University Hospitals, Switzerland (F.S., O.R.)
| | - Olivier Rutschmann
- Emergency Department, Geneva University Hospitals, Switzerland (F.S., O.R.)
| | | | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Switzerland (H.R.-E., M.R.)
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Moumneh T, Sun BC, Baecker A, Park S, Redberg R, Ferencik M, Lee MS, Douillet D, Roy PM, Sharp AL. Identifying Patients with Low Risk of Acute Coronary Syndrome Without Troponin Testing: Validation of the HEAR Score. Am J Med 2021; 134:499-506.e2. [PMID: 33127371 DOI: 10.1016/j.amjmed.2020.09.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/24/2020] [Accepted: 09/24/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Current guidelines for patients with suspected acute myocardial infarction are mainly based on troponin testing, commonly requiring an emergency department visit. HEAR score (History, Electrocardiogram, Age, and Risk factors) is a risk stratification tool validated in Europe, deduced from the HEART score (History, Electrocardiogram, Age, Risk factors, and Troponin), already implemented in clinical practice. We aimed to validate the HEAR score to rule out an acute myocardial infarction without needing biomarker testing. METHODS Retrospective cohort study at 15 emergency departments between May 2016 and December 2017. All adult encounters evaluated for possible acute myocardial infarction with a physician-documented HEART score for health plan members of Kaiser Permanente Southern California were included. Patients with an ST-segment elevation myocardial infarction, those under hospice care, or with a "do not resuscitate" status were excluded. HEAR scores from 0-8 were calculated for each encounter and used to report 30-day acute myocardial infarction or all-cause mortality for each score. RESULTS There were 22,109 patient encounters included in the study. Overall, 30-day acute myocardial infarction or death occurred in 1.1% of patients. Among the 4106 patients (19%) with a HEAR score <2, 3 died and 2 experienced an acute myocardial infarction within 30 days (0.1%; 95% confidence interval, 0.1-0.3). Sensitivity and specificity were 97.9% and 18.8%, respectively. CONCLUSIONS A low HEAR score may accurately identify patients with a very low risk of 30-day acute myocardial infarction or death, representing a cohort of patients who might appropriately forego biomarker testing. Future research is warranted to assess the impact of implementing the HEAR score into routine clinical practice.
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Affiliation(s)
- Thomas Moumneh
- Département de Médecine d'Urgence, CHU d'Angers, Institut MITOVASC, UMR CNRS 6015 UMR INSERM 1083, Université d'Angers, Angers, France.
| | - Benjamin C Sun
- Department of Emergency Medicine, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Aileen Baecker
- Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena
| | - Stacy Park
- Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena
| | - Rita Redberg
- Division of Cardiology, University of California, San Francisco
| | - Maros Ferencik
- Oregon Health and Science University, Knight Cardiovascular Institute, Portland
| | - Ming-Sum Lee
- Division of Cardiology, Kaiser Permanente Southern California, Los Angeles Medical Center
| | - Delphine Douillet
- Département de Médecine d'Urgence, CHU d'Angers, Institut MITOVASC, UMR CNRS 6015 UMR INSERM 1083, Université d'Angers, Angers, France
| | - Pierre-Marie Roy
- Département de Médecine d'Urgence, CHU d'Angers, Institut MITOVASC, UMR CNRS 6015 UMR INSERM 1083, Université d'Angers, Angers, France
| | - Adam L Sharp
- Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena; Department of Health Systems Science, Kaiser Permanente School of Medicine, Pasadena
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Douillet D, Roy PM, Penaloza A. Suspected Acute Pulmonary Embolism: Gestalt, Scoring Systems, and Artificial Intelligence. Semin Respir Crit Care Med 2021; 42:176-182. [PMID: 33592653 DOI: 10.1055/s-0041-1723936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Pulmonary embolism (PE) remains a diagnostic challenge in 2021. As the pathology is potentially fatal and signs and symptoms are nonspecific, further investigations are classically required. Based on the Bayesian approach, clinical probability became the keystone of the diagnostic strategy to rule out PE in the case of a negative testing. Several clinical probability assessment methods are validated: gestalt, the Wells score, or the revised Geneva score. While the debate persists as to the best way to assess clinical probability, its assessment allows for the good interpretation of the investigation results and therefore directs the correct diagnostic strategy. The wide availability of computed tomography pulmonary angiography (CTPA) resulted in a major increase in investigations with a moderate increase in diagnosis, without any notable improvement in patient outcomes. This leads to a new challenge for PE diagnosis which is the limitation of the number of testing for suspected PE. We review different strategies recently developed to achieve this goal. The last challenge concerns the implementation in clinical practice. Two approaches are developed: simplification of the strategies versus the use of digital support tools allowing more sophisticated strategies. Artificial intelligence with machine-learning algorithms will probably be a future tool to guide the physician in this complex approach concerning acute PE suspicion.
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Affiliation(s)
- Delphine Douillet
- Emergency Department, Angers University Hospital, INSERM 1083, Health Faculty, UNIV Angers, F-CRIN INNOVTE, Angers, France
| | - Pierre-Marie Roy
- Emergency Department, Angers University Hospital, INSERM 1083, Health Faculty, UNIV Angers, F-CRIN INNOVTE, Angers, France
| | - Andrea Penaloza
- Emergency Department, Cliniques Universitaires Saint Luc, UCLouvain, F-CRIN INNOVTE, Brussels, Belgium
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Morin F, Douillet D, Hamel JF, Rakotonjanahary J, Dupriez F, Savary D, Aubé C, Riou J, Dubée V, Roy PM. Point-of-care ultrasonography for risk stratification of non-critical COVID-19 patients on admission (POCUSCO): a study protocol of an international study. BMJ Open 2021; 11:e041118. [PMID: 33568367 PMCID: PMC7878051 DOI: 10.1136/bmjopen-2020-041118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 01/05/2021] [Accepted: 01/21/2021] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION In the context of the COVID-19 pandemic, early identification of patients who are likely to get worse is a major concern. Severity mainly depends on the development of acute respiratory distress syndrome (ARDS) with a predominance of subpleural lesions. Lung point-of-care ultrasonography (L-POCUS) is highly effective in detecting pulmonary peripheral patterns and may be appropriate for examining patients with COVID-19. We suggest that L-POCUS performed during the initial examination may identify patients with COVID-19 who are at a high risk of complicated treatment or unfavourable evolution. METHODS AND ANALYSIS Point-of-care ultrasonography for risk stratification of non-critical COVID-19 patients on admission is a prospective, multicentre study. Adult patients visiting the emergency department (ED) of participating centres for suspected or confirmed COVID-19 are assessed for inclusion. Included patients have L-POCUS performed within 48 hours following ED admission. The severity of lung damage is assessed using the L-POCUS score based on 36 points for ARDS. Apart from the L-POCUS score assessment, patients are treated as recommended by the WHO. For hospitalised patients, a second L-POCUS is performed at day 5±3. A follow-up is carried out on day 14, and the patient's status according to the Ordinal Scale for Clinical Improvement for COVID-19 from the WHO is recorded.The primary outcome is the rate of patients requiring intubation or who are dead from any cause during the 14 days following inclusion. We will determine the area under the ROC curve of L-POCUS. ETHICS AND DISSEMINATION The protocol has been approved by the French and Belgian Ethics Committees and is carried out in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. The study is funding by a grant from the French Health Ministry, and its findings will be disseminated in peer-reviewed journals and at scientific conferences. TRIAL REGISTRATION NUMBER NCT04338100.
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Affiliation(s)
- François Morin
- Department of Emergency Medicine, University Hospital of Angers, Univ Angers, Angers, France
| | - Delphine Douillet
- Department of Emergency Medicine, University Hospital of Angers, Univ Angers, Angers, France
- Institut MitoVasc, UMR CNRS 6215 INSERM 1083, Angers, France
| | - Jean-Francois Hamel
- Department of Methodology and Biostatistics, University Hospital of Angers, Univ Angers, Angers, France
| | - Josué Rakotonjanahary
- Department of Pediatric Oncology, University Hospital of Angers, Univ Angers, Angers, France
| | - Florence Dupriez
- Department of Emergency Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Dominique Savary
- Department of Emergency Medicine, University Hospital of Angers, Univ Angers, Angers, France
- IRSET (Institut de recherche en santé, environnement et travail) - UMR_S 1085, F-49000, Angers, France
| | - Christophe Aubé
- Department of Radiology, University Hospital of Angers, Univ Angers, Angers, France
| | - Jeremie Riou
- Department of Methodology and Biostatistics, University Hospital of Angers, Univ Angers, Angers, France
| | - Vincent Dubée
- Infectious Diseases and Tropical Medicine, University Hospital of Angers, Univ Angers, Angers, France
| | - Pierre-Marie Roy
- Department of Emergency Medicine, University Hospital of Angers, Univ Angers, Angers, France
- Institut MitoVasc, UMR CNRS 6215 INSERM 1083, Angers, France
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Couturaud F, Bertoletti L, Pastre J, Roy PM, Le Mao R, Gagnadoux F, Paleiron N, Schmidt J, Sanchez O, De Magalhaes E, Kamara M, Hoffmann C, Bressollette L, Nonent M, Tromeur C, Salaun PY, Barillot S, Gatineau F, Mismetti P, Girard P, Lacut K, Lemarié CA, Meyer G, Leroyer C. Prevalence of Pulmonary Embolism Among Patients With COPD Hospitalized With Acutely Worsening Respiratory Symptoms. JAMA 2021; 325:59-68. [PMID: 33399840 PMCID: PMC7786241 DOI: 10.1001/jama.2020.23567] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE The prevalence of pulmonary embolism in patients with chronic obstructive pulmonary disease (COPD) and acutely worsening respiratory symptoms remains uncertain. OBJECTIVE To determine the prevalence of pulmonary embolism in patients with COPD admitted to the hospital for acutely worsening respiratory symptoms. DESIGN, SETTING, AND PARTICIPANTS Multicenter cross-sectional study with prospective follow-up conducted in 7 French hospitals. A predefined pulmonary embolism diagnostic algorithm based on Geneva score, D-dimer levels, and spiral computed tomographic pulmonary angiography plus leg compression ultrasound was applied within 48 hours of admission; all patients had 3-month follow-up. Patients were recruited from January 2014 to May 2017 and the final date of follow-up was August 22, 2017. EXPOSURES Acutely worsening respiratory symptoms in patients with COPD. MAIN OUTCOMES AND MEASURES The primary outcome was pulmonary embolism diagnosed within 48 hours of admission. Key secondary outcome was pulmonary embolism during a 3-month follow-up among patients deemed not to have venous thromboembolism at admission and who did not receive anticoagulant treatment. Other outcomes were venous thromboembolism (pulmonary embolism and/or deep vein thrombosis) at admission and during follow-up, and 3-month mortality, whether venous thromboembolism was clinically suspected or not. RESULTS Among 740 included patients (mean age, 68.2 years [SD, 10.9 years]; 274 women [37.0%]), pulmonary embolism was confirmed within 48 hours of admission in 44 patients (5.9%; 95% CI, 4.5%-7.9%). Among the 670 patients deemed not to have venous thromboembolism at admission and who did not receive anticoagulation, pulmonary embolism occurred in 5 patients (0.7%; 95% CI, 0.3%-1.7%) during follow-up, including 3 deaths related to pulmonary embolism. The overall 3-month mortality rate was 6.8% (50 of 740; 95% CI, 5.2%-8.8%). The proportion of patients who died during follow-up was higher among those with venous thromboembolism at admission than the proportion of those without it at admission (14 [25.9%] of 54 patients vs 36 [5.2%] of 686; risk difference, 20.7%, 95% CI, 10.7%-33.8%; P < .001). The prevalence of venous thromboembolism was 11.7% (95% CI, 8.6%-15.9%) among patients in whom pulmonary embolism was suspected (n = 299) and was 4.3% (95% CI, 2.8%-6.6%) among those in whom pulmonary embolism was not suspected (n = 441). CONCLUSIONS AND RELEVANCE Among patients with chronic obstructive pulmonary disease admitted to the hospital with an acute worsening of respiratory symptoms, pulmonary embolism was detected in 5.9% of patients using a predefined diagnostic algorithm. Further research is needed to understand the possible role of systematic screening for pulmonary embolism in this patient population.
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Affiliation(s)
- Francis Couturaud
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Brest, France
- EA 3878, INSERM CIC 1412, Université de Bretagne Occidentale, Brest, France
- FCRIN INNOVTE, France
| | - Laurent Bertoletti
- FCRIN INNOVTE, France
- Service de Médecine Vasculaire et Thérapeutique, Centre Hospitalo-Universitaire de Saint-Etienne, Saint-Etienne, France
- INSERM CIC 1408, INSERM UMR 1059, Université Jean Monnet, Saint-Etienne, France
| | - Jean Pastre
- Service de Pneumologie et de Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
- INSERM UMR S 1140, Université de Paris; Paris, France
| | - Pierre-Marie Roy
- FCRIN INNOVTE, France
- Service des urgences, Centre Hospitalo-Universitaire d’Angers, France
- Institut MITOVASC, EA 3860, Université d'Angers, Angers, France
| | - Raphael Le Mao
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Brest, France
- EA 3878, INSERM CIC 1412, Université de Bretagne Occidentale, Brest, France
- FCRIN INNOVTE, France
| | - Frédéric Gagnadoux
- Département de Pneumologie, Centre Hospitalo-Universitaire d’Angers, France
- INSERM UMR1063, Université d’Angers, Angers, France
| | - Nicolas Paleiron
- Service de pneumologie-allergologie-cancérologie thoracique, HIA Sainte Anne, Toulon, France
| | - Jeannot Schmidt
- FCRIN INNOVTE, France
- Service des urgences, Centre Hospitalo-Universitaire de Clermont-Ferrand, France
- UMR 6024 UCA-CNRS, Université de Clermont-Ferrand, Clermont-Ferrand, France
| | - Olivier Sanchez
- FCRIN INNOVTE, France
- Service de Pneumologie et de Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
- INSERM UMR S 1140, Université de Paris; Paris, France
| | - Elodie De Magalhaes
- FCRIN INNOVTE, France
- Service de Médecine Vasculaire et Thérapeutique, Centre Hospitalo-Universitaire de Saint-Etienne, Saint-Etienne, France
- INSERM CIC 1408, INSERM UMR 1059, Université Jean Monnet, Saint-Etienne, France
| | - Mariam Kamara
- Service des urgences, Centre Hospitalier de Quimper, Quimper, France
| | - Clément Hoffmann
- EA 3878, INSERM CIC 1412, Université de Bretagne Occidentale, Brest, France
- Service d’Echo-doppler Vasculaire, Centre Hospitalo-Universitaire de Brest, Brest, France
| | - Luc Bressollette
- EA 3878, INSERM CIC 1412, Université de Bretagne Occidentale, Brest, France
- FCRIN INNOVTE, France
- Service d’Echo-doppler Vasculaire, Centre Hospitalo-Universitaire de Brest, Brest, France
| | - Michel Nonent
- EA 3878, INSERM CIC 1412, Université de Bretagne Occidentale, Brest, France
- Service de radiologie, Centre Hospitalo-Universitaire de Brest, Brest, France
| | - Cécile Tromeur
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Brest, France
- EA 3878, INSERM CIC 1412, Université de Bretagne Occidentale, Brest, France
- FCRIN INNOVTE, France
| | - Pierre-Yves Salaun
- FCRIN INNOVTE, France
- Service de Médecine Nucléaire, Centre Hospitalo-Universitaire de Brest, France
- EA 3878, Université de Bretagne Occidentale, Brest, France
| | - Sophie Barillot
- INSERM CIC 1412, Centre Hospitalo-Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Florence Gatineau
- INSERM CIC 1412, Centre Hospitalo-Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Patrick Mismetti
- FCRIN INNOVTE, France
- Service de Médecine Vasculaire et Thérapeutique, Centre Hospitalo-Universitaire de Saint-Etienne, Saint-Etienne, France
- INSERM CIC 1408, INSERM UMR 1059, Université Jean Monnet, Saint-Etienne, France
| | - Philippe Girard
- FCRIN INNOVTE, France
- Département Thoracique, Institut Mutualiste Montsouris, Paris, France
| | - Karine Lacut
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Brest, France
- EA 3878, INSERM CIC 1412, Université de Bretagne Occidentale, Brest, France
- FCRIN INNOVTE, France
| | - Catherine A. Lemarié
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Brest, France
- EA 3878, INSERM CIC 1412, Université de Bretagne Occidentale, Brest, France
- FCRIN INNOVTE, France
- INSERM 1078, Université de Bretagne Occidentale, Brest, France
| | - Guy Meyer
- FCRIN INNOVTE, France
- Service de Pneumologie et de Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
- INSERM UMR S 970, Université de Paris, Paris, France
| | - Christophe Leroyer
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Brest, France
- EA 3878, INSERM CIC 1412, Université de Bretagne Occidentale, Brest, France
- FCRIN INNOVTE, France
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Bouget J, Huet MC, Roy PM, Viglino D, Lacut K, Pavageau L, Oger E. Acute, major muscular hematoma associated with antithrombotic agents: A multicenter real-world cohort. Thromb Res 2020; 199:54-58. [PMID: 33429124 DOI: 10.1016/j.thromres.2020.12.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/17/2020] [Accepted: 12/18/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is little data on major muscular hematomas and the little there is has mainly focused on patients exposed to oral anticoagulants. OBJECTIVE To describe the clinical characteristics, management and outcomes of patients admitted to emergency department (ED) for major muscular hematoma associated with an antithrombotic agent, and to identify predictors of in-hospital mortality. PATIENTS AND METHODS Over a three-year period, all consecutive cases of adult patients admitted to the ED of 5 tertiary care hospitals for major muscular hematoma while exposed to an antithrombotic agent were prospectively collected and medically validated. Clinical and biological data, therapeutic management of the bleeding event, and in-hospital mortality were collected from the medical records and compared across five groups of hematoma locations. Potential confounders were taken in account using a multivariate binomial regression model. RESULTS Three hundred and seventy-five patients were included (mean age = 81.4 years): 271 were exposed to vitamin K antagonists, 58 to parenteral anticoagulants (heparin, LMWH, fondaparinux), 33 to antiplatelets, and 13 to direct oral anticoagulants. The muscular hematomas were located in the lower limbs (n = 198), the rectus sheath (n = 71), the iliopsoas (n = 45), the upper limbs (n = 33), or elsewhere (n = 28). Reversal therapy was prescribed for 48.5% of patients, red cell transfusions for 63.6%, surgery for 12.3% and embolization for 3.5%. For 84% of patients, hospitalization was required, with a median length of stay of 10 days. Overall, in-hospital mortality was 8.5%. Reversal therapy, the need for intensive care and mortality were significantly more frequent among patients with iliopsoas hematomas. The independent predictors of in-hospital mortality were: decrease in mean arterial pressure (RR = 1.84), decrease in hemoglobin level (RR = 1.37) and the iliopsoas location (RR = 3.06). CONCLUSION Frail elderly patients with major muscular hematomas linked to antithrombotic agents risk substantial morbidity and in-hospital mortality. The iliopsoas location was the most life-threatening bleeding site. Close observation of this population is warranted to ensure better outcomes.
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Affiliation(s)
- Jacques Bouget
- Univ Rennes, CHU Rennes, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, F 35043 Rennes, France
| | | | - Pierre-Marie Roy
- Emergency Department, Centre Hospitalier Universitaire, Institut MITOVASC, Université d'Angers, Angers, France; F-CRIN INNOVTE, France
| | - Damien Viglino
- Emergency Department, Grenoble-Alpes University Hospital, F 38043 Grenoble, France
| | - Karine Lacut
- CIC 1412, Université de Bretagne Loire, Université de Brest, INSERM CIC 1412, CHRU de Brest, F 29200 Brest, France
| | - Laure Pavageau
- Emergency Department, University hospital, F 44093 Nantes, France
| | - Emmanuel Oger
- Univ Rennes, CHU Rennes, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, F 35043 Rennes, France.
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Gendron N, Chocron R, Billoir P, Brunier J, Camoin-Jau L, Tuffigo M, Faille D, Teissandier D, Gay J, de Raucourt E, Suner L, Bonnet C, Martin AC, Lasne D, Ladhari C, Lebreton A, Bertoletti L, Ajzenberg N, Gaussem P, Morange PE, Le Cam Duchez V, Viallon A, Roy PM, Lillo-le Louët A, Smadja DM. Dabigatran Level Before Reversal Can Predict Hemostatic Effectiveness of Idarucizumab in a Real-World Setting. Front Med (Lausanne) 2020; 7:599626. [PMID: 33392223 PMCID: PMC7772865 DOI: 10.3389/fmed.2020.599626] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/10/2020] [Indexed: 02/04/2023] Open
Abstract
Background: Idarucizumab has been included in guidelines for the management of bleeding or surgical procedure in dabigatran-treated patients without need for biological monitoring. The aim of the study was to assess the prognostic value of dabigatran plasma level before reversal to test the hemostatic efficacy of idarucizumab. The secondary objectives were (i) to analyze plasma dabigatran level according to the risk of rebound and (ii) to evaluate the incidence of post-reversal non-favorable clinical outcomes (including thromboembolism, bleeding, antithrombotic, and death) and antithrombotic resumption. Methods and Results: This was an observational multicentric cohort study, which included all French patients who required idarucizumab for dabigatran reversal. Between May 2016 and April 2019, 87 patients from 21 French centers were enrolled. Patients received idarucizumab for overt bleeding (n = 61), urgent procedures (n = 24), or overdose without bleeding (n = 2). Among patients with major bleeding (n = 57), treatment with idarucizumab was considered effective in 44 (77.2%) of them. Patients who did not achieve effective hemostasis after reversal had a significantly higher mean level of plasma dabigatran at baseline (524.5 ± 386 vs. 252.8 ng/mL ± 235, p = 0.033). Furthermore, patients who did not achieve effective hemostasis after reversal had less favorable outcomes during follow-up (46.2 vs. 81.8%, p = 0.027). ROC curve identified a cutoff of 264 ng/mL for dabigatran level at admission to be predictive of ineffective hemostasis. No plasma dabigatran rebound was observed after reversal in patients with dabigatran plasma level < 264 ng/mL at baseline. Conclusion: This retrospective study shows that dabigatran level before reversal could predict hemostatic effectiveness and dabigatran plasma rebound after idarucizumab injection.
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Affiliation(s)
- Nicolas Gendron
- Université de Paris, Innovative Therapies in Haemostasis, INSERM, Paris, France.,Hematology Department and Biosurgical Research Lab (Carpentier Foundation), AH-HP, Georges Pompidou European Hospital, Paris, France
| | - Richard Chocron
- Université de Paris, PARCC, INSERM, Paris, France.,Emergency Department, AH-HP, Georges Pompidou European Hospital, Paris, France
| | - Paul Billoir
- Normandie Univ, UNIROUEN, INSERM Rouen University Hospital, Vascular Hemostasis Unit, Rouen, France
| | - Julien Brunier
- CHU-Pellegrin, Laboratory of Hematology, Bordeaux, France
| | | | - Marie Tuffigo
- CHU Angers, Laboratory of Hematology, Angers, France
| | - Dorothée Faille
- Université de Paris, Laboratory of Vascular Translational Science, INSERM, Paris, France.,Laboratory of Hematology, AH-HP, Bichat Hospital, Paris, France
| | - Dorian Teissandier
- CHU Clermont-Ferrand, Emergency Medicine Department, Clermont-Ferrand, France
| | - Juliette Gay
- Université de Paris, Innovative Therapies in Haemostasis, INSERM, Paris, France.,Hematology Department, AH-HP, Georges Pompidou European Hospital, Paris, France
| | - Emmanuelle de Raucourt
- Université de Paris, LVTS, INSERM, Paris, France.,Hematology Department, AP-HP, Hôpital Beaujon, Clichy, France
| | - Ludovic Suner
- Sorbonne Université, Inserm, Centre de Recherche Saint-Antoine, AP-HP, Hôpital Saint-Antoine, Hématologie Biologique, Paris, France
| | - Corentin Bonnet
- CHU Sud Réunion, Anaestesiology Department, Saint-Pierre, La Réunion, France
| | - Anne-Céline Martin
- Université de Paris, Innovative Therapies in Haemostasis, INSERM, Paris, France.,Cardiology Department, AH-HP, Georges Pompidou European Hospital, Paris, France
| | - Dominique Lasne
- AP-HP, CHU Necker-Enfants Malades, Department of Biogical Hematology, Paris, France
| | - Chayma Ladhari
- CHU Montpellier, Centre Régional de Pharmacovigilance, Montpellier, France
| | - Aurélien Lebreton
- CHU Clermont-Ferrand, Laboratory of Hematology, Clermont-Ferrand, France
| | - Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, CHU de Saint-Étienne, INSERM, Université Jean-Monnet, INSERM, CHU de Saint-Étienne, Saint-Étienne, France.,F-CRIN INNOVTE, Saint-Étienne, France
| | - Nadine Ajzenberg
- Université de Paris, Laboratory of Vascular Translational Science, INSERM, Paris, France.,Laboratory of Hematology, AH-HP, Bichat Hospital, Paris, France
| | - Pascale Gaussem
- Université de Paris, Innovative Therapies in Haemostasis, INSERM, Paris, France.,Hematology Department, AH-HP, Georges Pompidou European Hospital, Paris, France
| | - Pierre-Emmanuel Morange
- AP-HM, CHU Timone, Laboratory of Hematology, Marseille, France.,F-CRIN INNOVTE, Saint-Étienne, France.,C2VN, Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France
| | - Véronique Le Cam Duchez
- Normandie Univ, UNIROUEN, INSERM Rouen University Hospital, Vascular Hemostasis Unit, Rouen, France
| | - Alain Viallon
- CHU Saint-Étienne, Emergency Department, Saint-Étienne, France
| | - Pierre-Marie Roy
- F-CRIN INNOVTE, Saint-Étienne, France.,CHU Angers, Emergency Department and Vascular Medicine Ward, Université d'Angers, MITOVASC Institut, UMR (CNRS 6015-INSERM 1083), Angers, France
| | - Agnès Lillo-le Louët
- Université de Paris, Innovative Therapies in Haemostasis, INSERM, Paris, France.,Département de Pharmacovigilance, AH-HP, Georges Pompidou European Hospital, Paris, France
| | - David M Smadja
- Université de Paris, Innovative Therapies in Haemostasis, INSERM, Paris, France.,Hematology Department and Biosurgical Research Lab (Carpentier Foundation), AH-HP, Georges Pompidou European Hospital, Paris, France.,F-CRIN INNOVTE, Saint-Étienne, France
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45
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Elias A, Schmidt J, Bellou A, Le Gal G, Roy PM, Mismetti P, Meyer G, Clarke M. Opinion and practice survey about the use of prognostic models in acute pulmonary embolism. Thromb Res 2020; 198:40-48. [PMID: 33278785 DOI: 10.1016/j.thromres.2020.10.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 10/25/2020] [Accepted: 10/26/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Methods for prognosis assessment and patient management in acute pulmonary embolism (PE) are much debated among physicians. We conducted an online survey to determine physician's attitudes and barriers towards the use of prognostic models when treating patients with acute PE. METHOD Physicians members of the French and the European scientific societies for emergency medicine or of a French thrombosis research network were reached by their respective scientific societies and invited to participate via email. The questionnaire was a mixture of close-ended with yes-no or multiple-choice options and a small number of open-ended questions. RESULTS The survey included 461 respondents. The most commonly used prognostic tools were clinical judgment (36%) and prognostic models (29.5%). Prognostic models were used by 57% of respondents in more than half of all cases and prognostic indicators by 62% in addition to prognostic models. Affiliation group and type of hospital emerged as independent predictors for choosing prognostic models. Many (52%) reported lack of familiarity with the models and reported clinical judgment (60%) or hospital checklists (73%) as being as good as or better than prognostic models. The highest acceptable 30-day mortality rate limit for early discharge or outpatient management was deemed to be 1%, but few patients are discharged early or completely managed on an outpatient basis. CONCLUSIONS This survey provides new information for implementing knowledge translation strategies to improve prognostic risk assessment for acute PE patients, and highlights the need for considering the use of clinical judgment and hospital checklists in future clinical research.
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Affiliation(s)
- Antoine Elias
- Department for Continuing Education Professional Development, University of Oxford, Oxford, United Kingdom; Service de Médecine Vasculaire, Pôle Cardiologie-Vasculaire, Hôpital Sainte Musse, Centre Hospitalier Intercommunal Toulon La Seyne-sur-Mer, Toulon, France; INNOVTE (INvestigation Network On Venous ThromboEmbolism) F-CRIN (French Clinical Research Infrastructure) Network, France.
| | - Jeannot Schmidt
- INNOVTE (INvestigation Network On Venous ThromboEmbolism) F-CRIN (French Clinical Research Infrastructure) Network, France; Pôle Urgences, Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand, France; Université 1 d'Auvergne, Clermont Ferrand, France; French Society for Emergency Medicine (SFMU), France
| | - Abdelouahab Bellou
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center (BIDMC), Harvard Medical School, Boston, MA, USA; European Society for Emergency Medicine (EuSEM), Brussels, Belgium
| | - Grégoire Le Gal
- INNOVTE (INvestigation Network On Venous ThromboEmbolism) F-CRIN (French Clinical Research Infrastructure) Network, France; Thrombosis Program, Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Unit, Ottawa Health Research Institute, Ottawa, Ontario, Canada; The Ottawa Hospital, Ottawa, Ontario, Canada; Université de Brest, Brest, France
| | - Pierre-Marie Roy
- INNOVTE (INvestigation Network On Venous ThromboEmbolism) F-CRIN (French Clinical Research Infrastructure) Network, France; French Society for Emergency Medicine (SFMU), France; Département de Médecine d'Urgence, Centre Vasculaire et de la Coagulation, Centre Hospitalier Universitaire d'Angers, France; UMR (CNRS 6015 - INSERM 1083) et Institut MitoVasc, Université d'Angers, France
| | - Patrick Mismetti
- INNOVTE (INvestigation Network On Venous ThromboEmbolism) F-CRIN (French Clinical Research Infrastructure) Network, France; Service de Médecine Vasculaire et Thérapeutique, Centre Hospitalier Universitaire de Saint-Etienne, France; Université Jean Monnet, Groupe d'Investigation et de Recherche Clinique sur la Thrombose, Saint-Etienne, France; Unité de Pharmacologie Clinique, Centre Hospitalier Universitaire de Saint-Etienne, France
| | - Guy Meyer
- INNOVTE (INvestigation Network On Venous ThromboEmbolism) F-CRIN (French Clinical Research Infrastructure) Network, France; Service de Pneumologie, Hôpital Européen Georges Pompidou, France; Université Paris Descartes, Sorbonne, Paris Cité, France
| | - Mike Clarke
- Department for Continuing Education Professional Development, University of Oxford, Oxford, United Kingdom; Northern Ireland Network for Trials Methodology Research, Queen's University Belfast, Belfast, United Kingdom
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Douillet D, Mahieu R, Boiveau V, Vandamme YM, Armand A, Morin F, Savary D, Dubée V, Annweiler C, Roy PM. Outpatient management or hospitalization of patients with proven or suspected SARS-CoV-2 infection: the HOME-CoV rule. Intern Emerg Med 2020; 15:1525-1531. [PMID: 32888112 PMCID: PMC7550768 DOI: 10.1007/s11739-020-02483-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 08/20/2020] [Indexed: 01/08/2023]
Abstract
In the context of the COVID-19 pandemic and overloaded hospitals, a central issue is the need to define reliable and consensual criteria for hospitalization or outpatient management in mild cases of COVID-19. Our aim was to define an easy-to-use clinical rule aiming to help emergency physicians in hospitalization or outpatient management decision-making for patients with suspected or confirmed SARS-CoV-2 infection (the HOME-CoV rule). The Delphi method was used to reach a consensus of a large panel of 51 experts: emergency physicians, geriatricians, infectious disease specialists, and ethical consultants. A preliminary list of eligible criteria was compiled based on a literature review. Four rounds of anonymized expert consultations were performed. The experts were asked to score each item as relevant, possibly relevant and non-relevant, as major or minor, and to choose the cut-off. They were also able make suggestions and remarks. Eight criteria constituting the HOME-CoV were selected: six correspond to the severity of clinical signs, one to the clinical course (clinically significant worsening within the last 24 h), and the last corresponds to the association of a severe comorbidity and an inadequate living context. Hospitalization is deemed necessary if a patient meets one or more of the criteria. In the end, 94.4% of the experts agreed with the defined rule. Thanks to the Delphi method, an absolute consensus was obtained of a large panel of experts on the HOME-CoV rule, a decision-making support mechanism for clinicians to target patients with suspected or confirmed COVID-19 requiring hospitalization.Trial registration: NCT04338841.
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Affiliation(s)
- Delphine Douillet
- Emergency Department, CHU Angers, 4 rue Larrey, 49100, Angers, France.
- UMR (CNRS 6015-INSERM 1083) et Institut MitoVasc, Université d'Angers, Angers, France.
| | - Rafaël Mahieu
- Department of Infectious Disease, CHU Angers, Université d'Angers, Angers, France
- CRCINA, Inserm, Université de Nantes, Nantes, France
| | - Violette Boiveau
- Emergency Department, CHU Angers, 4 rue Larrey, 49100, Angers, France
| | - Yves-Marie Vandamme
- Department of Infectious Disease, CHU Angers, Université d'Angers, Angers, France
| | - Aurore Armand
- Emergency Department, CHU Angers, 4 rue Larrey, 49100, Angers, France
| | - Francois Morin
- Emergency Department, CHU Angers, 4 rue Larrey, 49100, Angers, France
| | - Dominique Savary
- Emergency Department, CHU Angers, 4 rue Larrey, 49100, Angers, France
- EHESP, Irset, Inserm, UMR S1085, CAPTV CDC, Université Rennes, Rennes, France
| | - Vincent Dubée
- Department of Infectious Disease, CHU Angers, Université d'Angers, Angers, France
- CRCINA, Inserm, Université de Nantes, Nantes, France
| | - Cédric Annweiler
- Geriatric Department, CHU Angers, Angers, France
- Department of Medical Biophysics, Robarts Research Institute, Schulich School of Medicine and Dentistry, the University of Western Ontario, London, ON, Canada
| | - Pierre-Marie Roy
- Emergency Department, CHU Angers, 4 rue Larrey, 49100, Angers, France
- UMR (CNRS 6015-INSERM 1083) et Institut MitoVasc, Université d'Angers, Angers, France
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Douillet D, Schotte T, Monteiro-Rodrigues A, Morin F, Hamdan D, Barré G, Moumneh T, Léger M, Roy PM, Savary D, Templier F. First high-speed rail transport of patients with COVID-19 in Europe: the need for speed and safety. Emergencias 2020; 32:449-450. [PMID: 33275377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
| | | | | | - Francois Morin
- Emergency Department, Angers University Hospital, Angers, Francia
| | - David Hamdan
- Emergency Department, Angers University Hospital, Angers, Francia
| | | | - Thomas Moumneh
- Emergency Department, Angers University Hospital, Angers, Francia
| | - Maxime Léger
- Anesthesiology Department, Angers University Hospital, Angers, Francia
| | - Pierre-Marie Roy
- Emergency Department, Angers University Hospital, Angers, Francia
| | - Dominique Savary
- Emergency Department, Angers University Hospital, Angers, Francia
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Coelho J, Divernet-Queriaud M, Roy PM, Penaloza A, Le Gal G, Trinh-Duc A. Comparison of the Wells score and the revised Geneva score as a tool to predict pulmonary embolism in outpatients over age 65. Thromb Res 2020; 196:120-126. [PMID: 32862033 DOI: 10.1016/j.thromres.2020.07.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 07/09/2020] [Accepted: 07/09/2020] [Indexed: 12/14/2022]
Abstract
TITLE Comparison of the Wells score and the revised Geneva score as a tool to predict pulmonary embolism in outpatients over 65 years of age. INTRODUCTION The incidence and mortality of pulmonary embolism (PE) is high in the elderly. The Wells score (SW) and the revised Geneva score (RGS) have been validated in patient populations with a large age range. The aim of this study was to compare the predictive accuracy of these two scores in diagnosis of PE in patients over 65 years of age. METHOD A prospective multicentre study (nine French and three Belgian centres) was conducted at the same time as the PERCEPIC study. A total of 1757 patients admitted with suspected PE were included and divided into two groups according to age (≥65 years or <65 years). The pre-test probability of PE was assessed prospectively for the RGS. The SW was calculated retrospectively. The predictive accuracy of the two scores was compared by the area under the curve (AUC) of the ROC curves. RESULTS The overall prevalence of PE was 11.3%. The prevalence among patients aged ≥65 in the low, moderate and high pre-test probability groups, evaluated using the WS and was respectively 13.5% (CI 95%: CI 9.9-17.3), 28.2% (CI 22.1-34.3), 50% (CI 26-74) and 8.1% (CI 3.2-12.9), 22.3% (CI 18.2-26.3), 43.7% (CI 25.6-61.9) using the RGS. The AUC for the WS and RGS for patients aged ≥65 was 0.632 (CI 0.574-0.691) and 0.610 (CI 0.555-0.666). The difference between the AUCs was not statistically significant (p = .441). CONCLUSION In the population for this study, the WS and RGS have the same PE diagnostic accuracy in patients over age 65. This result should be validated in a prospective study that directly compares these scores.
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Affiliation(s)
- Julien Coelho
- Centre Hospitalier d'Agen-Nérac, Site St Esprit, 21 route de Villeneuve, 47923 Agen, France.
| | | | - Pierre-Marie Roy
- Emergency Department, Centre Hospitalier Universitaire Angers, Institut Mitovasc, Université d'Angers, Angers, France
| | - Andréa Penaloza
- Emergency Department, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Grégoire Le Gal
- Division of Hematology-Thrombosis Program, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Albert Trinh-Duc
- Centre Hospitalier d'Agen-Nérac, Site St Esprit, 21 route de Villeneuve, 47923 Agen, France
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Bouget J, Balusson F, Viglino D, Roy PM, Lacut K, Pavageau L, Oger E. Major bleeding risk and mortality associated with antiplatelet drugs in real-world clinical practice. A prospective cohort study. PLoS One 2020; 15:e0237022. [PMID: 32764775 PMCID: PMC7413418 DOI: 10.1371/journal.pone.0237022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/18/2020] [Indexed: 12/20/2022] Open
Abstract
Background Major bleedings other than gastrointestinal (GI) and intracranial (ICH) and mortality rates associated with antiplatelet drugs in real-world clinical practice are unknown. The objective was to estimate major bleeding risk and mortality among new users of antiplatelet drugs in real-world clinical practice. Methods and findings A population-based prospective cohort using the French national health data system (SNIIRAM), identified 69,911 adults living within five well-defined geographical areas, who were new users of antiplatelet drugs in 2013–2015 and who had not received any antithrombotics in 2012. Among them, 63,600 started a monotherapy and 6,311 a dual regimen. Clinical data for all adults referred for bleeding was collected from all emergency departments within these areas, and medically validated. Databases were linked using common key variables. The main outcome measure was time to major bleeding (GI, ICH and other bleedings). Secondary outcomes were death, and event-free survival (EFS). Hazard ratios (HR) were derived from adjusted Cox proportional hazard models. We used Inverse Propensity of Treatment Weighting as a stratified sensitivity analysis according to the antiplatelet monotherapy indication: primary prevention without cardiovascular (CV) risk factors, with CV risk factors, and secondary prevention. We observed 250 (0.36%) major haemorrhages, 81 ICH, 106 GI and 63 other types of bleeding. Incidences were twice as high in dual therapy as in monotherapy. Compared to low-dose aspirin (≤ 100 mg daily), high-dose (> 100 up to 325 mg daily) was associated with an increased risk of ICH (HR = 1.80, 95%CI 1.10 to 2.95). EFS was improved by high-dose compared to low-dose aspirin (1.41, 1.04 to 1.90 and 1.32, 1.03 to 1.68) and clopidogrel (1.30, 0.73 to 2.3 and 1.7, 1.24 to 2.34) respectively in primary prevention with and without CV risk factors. Conclusion The incidence of major bleeding and mortality was low. In monotherapy, low-dose aspirin was the safest therapeutic option whatever the indication. Trial registration NCT02886533.
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Affiliation(s)
- Jacques Bouget
- EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Univ Rennes, CHU Rennes, Rennes, France
| | - Frédéric Balusson
- EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Univ Rennes, CHU Rennes, Rennes, France
| | - Damien Viglino
- Emergency Department, Grenoble-Alpes University Hospital, Grenoble, France
| | - Pierre-Marie Roy
- Emergency Department, Centre Hospitalier Universitaire, Institut MITOVASC, Université d'Angers, Angers, France.,F-CRIN INNOVTE, France
| | - Karine Lacut
- CIC 1412, Université de Bretagne Loire, Université de Brest, INSERM CIC 1412, CHRU de Brest, Brest, France
| | - Laure Pavageau
- Emergency Department, University Hospital, Nantes, France
| | - Emmanuel Oger
- EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Univ Rennes, CHU Rennes, Rennes, France
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Bouget J, Balusson F, Maignan M, Pavageau L, Roy PM, Lacut K, Scailteux LM, Nowak E, Oger E. Major bleeding risk associated with oral anticoagulant in real clinical practice. A multicentre 3-year period population-based prospective cohort study. Br J Clin Pharmacol 2020; 86:2519-2529. [PMID: 32415705 DOI: 10.1111/bcp.14362] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 04/21/2020] [Accepted: 05/01/2020] [Indexed: 12/11/2022] Open
Abstract
AIMS The objective was to compare major bleeding risk of direct oral anticoagulants (DOACs; per type and dose) with vitamin K antagonists (VKAs), irrespective of indication, using real-world data. METHODS A population-based prospective cohort study, using the French national health data system (SNIIRAM), identified 47 469 adults living within 5 well-defined geographical areas, who were new users of oral anticoagulants in the period 2013-2015: 20 205 VKA users, 19 579 rivaroxaban users, 4225 dabigatran users and 3460 apixaban users. From all emergency departments within these areas, clinical data for all adults referred for bleeding was collected and medically validated. The databases were linked for common key variables. The main outcome measure was major bleeding: intracranial haemorrhage, major gastrointestinal bleeding and other major bleeding events. Hazard ratios were derived from adjusted Cox proportional hazard models. We used propensity score weighting as a sensitivity analysis, with separate analyses according to indications (atrial fibrillation or venous thromboembolism). RESULTS Compared to VKAs, high and low-dose DOACs were associated with a reduced risk of intracranial haemorrhage (adjusted hazard ratio 0.55, 95% confidence interval 0.37-0.82 and 0.54, 0.26-1.12 respectively), and a reduced risk of other major bleeding events (0.41, 0.29-0.58 and 0.41, 0.22-0.79 respectively), irrespective of duration and indication. Neither DOAC dose evidenced any significant difference from VKAs in terms of risk of major gastrointestinal bleeding. CONCLUSION There is a clear benefit of using DOACs with regard to intracranial haemorrhage. The study provides new insight into major gastrointestinal and other major bleeding events.
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Affiliation(s)
- Jacques Bouget
- Univ Rennes, CHU Rennes, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Rennes, France
| | - Frédéric Balusson
- Univ Rennes, CHU Rennes, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Rennes, France
| | - Maxime Maignan
- Emergency Department, University Hospital, Grenoble, France
| | - Laure Pavageau
- Emergency Department, University hospital, Nantes, France
| | | | - Karine Lacut
- CIC 1412, Université de Bretagne Loire, Université de Brest, INSERM, CHRU de Brest, Brest, France
| | - Lucie-Marie Scailteux
- Univ Rennes, CHU Rennes, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Rennes, France
| | - Emmanuel Nowak
- CIC 1412, Université de Bretagne Loire, Université de Brest, INSERM, CHRU de Brest, Brest, France
| | - Emmanuel Oger
- Univ Rennes, CHU Rennes, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Rennes, France
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