P6459Comparison of the new BLLADS score with other scores for the prediction of major bleeding in patients with acute pulmonary embolism

Background

Hemorrhagic complications are a major obstacle for aggressive antithrombotic therapy in patients with acute pulmonary embolism (PE).

Objectives

We aimed to develop a simple risk score for predicting major bleeding (MB) in patients with acute PE using medical history and laboratory data at admission, including the potential influence of thrombolytic therapy, and to compare its predictive power to bleeding risk scores previously developed for patients with atrial fibrillation or venous thromboembolism.

Methods

A total of 630 consecutive patients treated for PE in six Serbian University hospitals were followed up for the occurrence of MB over a 90-day period after admission. A 6-component bleeding risk score was developed after Cox regression analysis of possible variables presented at admission. The use of thrombolytic therapy was also tested as a risk factor for bleeding and was integrated into the score. The ATRIA, HAS BLED, RIETE and VTE-BLEED scores were calculated for each patient at baseline and the predictive performances were compared with new score using c-statistics.

Results

MB occurred in 61 (9.7%) patients during the 90-day follow-up, with no increased risk of all-cause mortality (p=0.108). Six independent factors associated with MB were included in the final model (previous bleeding, leukocyte count ≥14x109/L, receipt of thrombolytic therapy, anemia, drugs associated with bleeding, and recent surgery; BLLADS). For the six- and five-variable models (without points for thrombolysis), C-indices were 0.774 (95% confidence interval [CI], 0.713–0.835, p<0.001) and 0.713 (95% CI, 0.639–0.788, p<0.001), respectively. The predictive power of the BLLADS score was found to be superior in comparison with other four scores: c-index 0.779 (95% CI 0.716–0.841, p<0.001), 0,614 (95% CI 0.535–0.692, p=0.005), 0.591 (95% CI 0.518–0.664, p=0.025), 0.589 (95% CI 0.518–0.659, p=0.029), 0.586 (95% CI 0.508–0.664, p=0.035), for continuous BLLADS, RIETE, VTE-BLEED, ATRIA and HAS BLED scores, respectively.

Conclusion

A simple six-variable score including the use of thrombolysis was developed with sufficient discriminative capacity comparing to current available scores for the prediction of 90-day MB for non-selected PE patients.

P6465Are we calculated enough? Glomerular filtration rate as a predictor of intra-hospital prognosis in patients with pulmonary embolism

Background

Pulmonary embolism (PE) can lead to multi-organ damage including an acute renal dysfunction which is associated with adverse events and high long-term mortality rate.

Purpose

The aim of our study was to investigate the predictive role of renal dysfunction on intrahospital mortality risk in patients hospitalized due to PE. The study was performed in intensive care units of six university hospitals.

Methods

The prospective cohort study comprised 665 consecutive patients with acute PE which was confirmed using MDCT. All patients underwent echocardiography examination on admission and blood samples were collected for troponin I (TnI), B-type natriuretic peptide (BNP) and routine laboratory analyses.

Results

Based on estimated glomerular filtration rate (GFR), patients were divided into three groups: first with the GFR <30ml/min, second with GFR 30–60 ml/min, and third with GFR >60 ml/min. During hospitalization in the first group the overall incidence of death was recorded in 28 (45.9%), in the second in 42 (18.9%), and in the third in 30 (7.9%) patients (p<0.0001). Pulmonary embolism as a cause of death was recorded in the first group in 18 (29.5%) patients, in the second in 25 (11.3%) and in the third in 17 (4.5%) patients (p<0.0001). Fatal bleeding was recorded in the first group in 1 (1.6%), in the second in 1 (0.5%) and in the third group in 3 (0.8%) patients (p<0.05). There were no significant differences regarding major bleeding frequency among the groups. Multivariate analysis showed that age, comorbidities, hemodynamic status, TnI, and GFR were strongly associated with an overall mortality rate and with death due to PE, while the use of anticoagulation therapy influenced the fatal bleeding rate. After controlling for age, we found that GFR on admission had a significant effect on in-hospital survival. Compared with patients in the third group, those from the second group had more than 2 fold increased mortality risk [OR 2.17 (CI 1.301–3.625), p=0.001], and patients in the first group had 6 fold higher risk of mortality [OR 6.006 (CI 3.487–6.006)]. In the ROC analysis GFR showed significant predictive value for intra-hospital mortality risk in PE patients [AUC= 0.725, 95% CI (0.68–0.78), p<0.001]. The highest sensitivity (64%) and specificity (70%) had GFR “cutoff” value of 59.12/min.

Conclusion

Renal dysfunction, on admission, in patients with acute PE is strongly associated with high intrahospital mortality risk and fatal bleeding. The estimation of GFR in these patients is important not only for prediction of the outcome but also for the prevention of bleeding complications, regarding the optimal dosage of anticoagulants. Even though it seems that GFR calculation is not still the clinical routine in PE.

P5591Efficacy and safety of lower dose slow infusion of t-PA for intermediate-risk pulmonary embolism patients with risk for bleeding

Background

Current guidelines do not recommend thrombolytic therapy for the treatment of intermediate-risk pulmonary embolism (PE) because of the tight balance between the benefit and safety with classic protocols.

Aim

The aim of this study was to compare the new thrombolytic protocol with lower-dose slow-infusion (LDSI) of tissue plasminogen activator (tPA) to classic 2-hours tPA infusion protocol or no-reperfusion in patients with intermediate-high risk PE with higher bleeding risk regarding 30-day efficacy and safety.

Methods

Among 849 patients with PE from the Serbian multicenter registry, 469 patients who fulfilled criteria for intermediate-risk PE were involved in the study. After propensity score matching 425 patients [263 (61.9%), 99 (23.3%) and 63 (14.8%) were treated with no-reperfusion, classic tPA protocol (100 mg for 2 hours) and LDSI of tPA (2–5 mg/hour either vie local catheter or systemic venous infusion with dose range of 25–50 mg)]. The basic characteristics of patients were well balanced between groups except that patients treated with LDSI of tPA had significantly higher usage of drugs which can be associated to bleeding and more previous bleeding events. Thirty day all-cause and PE-caused mortality and 7-day major bleeding were the main efficacy and safety end-points, respectively.

Results

All-cause and PE-cause 30-day mortality were 8.7% vs 16.2% vs 1.6% (Log rank p=0.007) and 4.5% vs 11.0% vs 0.0% (Log rank p=0.008) in patients with no-reperfusion, classic tPA protocol and LDSI of tPA protocol, respectively. Major bleeding at 7 days were 2.7% vs 8.1% vs 14.3% (Log rank p=0.001) in patients with no-reperfusion, classic tPA protocol and LDSI of tPA protocol, respectively. There was one fatal intracranial bleeding during catheter infusion of tPA.

Conclusion

Lower-dose slow-infusion of tPA protocol decreased significantly all-cause and PE-cause mortality at 30-day at the cost of excess of non-fatal major bleeding at 7-day in patients with intermediate-risk PE and higher risk for bleeding.

Acknowledgement/Funding

None

Incidence of erectile impotence secondary to transurethral resection of benign prostatic hyperplasia, assessed by preoperative and postoperative Snap Gauge tests

In an attempt to assess the impotence rate secondary to transurethral resection of the prostate more objectively than by merely interviewing patients, potency was evaluated with the Snap-Gauge test. The test was used preoperatively to recruit patients with intact potency. The 98 patients studied underwent transurethral resection of the prostate and were retested during postoperative night 4. Of the 98 patients 64 remained potent while 34 did not. These 34 men were retested 3 months later, and 26 were potent and 8 were impotent. Therefore, 8 of 98 patients (8.3%) became impotent as a consequence of transurethral resection of the prostate. The risk specific to subgroups in cases of small (less than 10 gm. resectable tissue) and larger adenomas is 11.1% and 7.7%, respectively, for men older than 65 years, and 7.1% and 0%, respectively, for men younger than 65 years. A selective indication taking into account patient age and prostatic size might further lower the already low impotence risk of transurethral resection of the prostate.

Laparoscopic dismembered pyeloplasty: preliminary report

As a reconstructive laparoscopic procedure, dismembered pyeloplasty was done in 5 patients: the laparoscopic procedure was completed in 4 and converted to an open operation in 1. Within this series operative time decreased from 390 to 190 minutes. The main operating time was devoted to laparoscopic suturing of the anastomosis. Spreading the renal pelvis by either pulling the sutures transcutaneously or with intra-abdominal stay sutures improved visualization and facilitated the anastomosis. Mean postoperative hospitalization was 8 days (range 7 to 10). After a mean followup of 9 months (range 6 to 15) excretory urography and renal scintigraphy revealed significant radiographic improvement and no obstruction in 4 patients. Compared to open pyeloplasty and endo-pyelotomy, laparoscopic pyeloplasty may combine the advantages of open surgery (excision of the stenosis and reduction of the renal pelvis) with those of minimally invasive surgery (minimal postoperative morbidity), provided the operative time can be shortened and the technique simplified.

[Initial experience with surgical uro-laparoscopy]

Preliminary experience with uro-laparoscopy was retrospectively analyzed to determine whether patients profited from the laparoscopic procedure. Between August 1991 und July 1993 we performed 53 operations laparoscopically. Four more began in this way but ended in open surgery. 29 varicocele procedures were carried out. A reduced postoperative morbidity, and hence a benefit, were obvious in 3/29 patients with bilateral varicocele, but probably not in the remaining 26/29 patients affected only on the left side. 13 pelvic lymphadenectomies in patients with prostatic carcinoma T1-3, elevated prostatic acid phosphatase, a PSA > 30 ng/ml and/or a suspected N+ on CT, served to identify 10 pN0 and 3 pN1 patients. Four of the pN0 patients with a T3 tumor were given radiotherapy. Six with a T2 tumor underwent radical prostatectomy, four with margin-negative specimens benefited from laparoscopic lymphadenectomy by securing a curative operation which according to established rules would otherwise have been withheld. Two patients with margin-positive specimens suffered harm from laparoscopic lymphadenectomy, which had led to a needless operation. Another lymphadenectomy performed on one more patient suffering from deep venous thrombosis of the left leg associated with pelvic lymphadenopathy established the benign histology of the enlarged lymph nodes with minimal morbidity. 10 nephrectomies were carried out for benign, clinically relevant lesions of the kidney, which are rare. They produced a clear-cut benefit for all patients as the postoperative morbidity was minimal. We conclude that the present indications for uro-laparoscopic procedures are either disputable or rare.(ABSTRACT TRUNCATED AT 250 WORDS)