Untargeted Multiomics Approach Coupling Lipidomics and Metabolomics Profiling Reveals New Insights in Diabetic Retinopathy

Diabetic retinopathy (DR) is a microvascular complication of diabetes mellitus (DM) which is the main cause of vision loss in the working-age population. Currently known risk factors such as age, disease duration, and hemoglobin A1c lack sufficient efficiency to distinguish patients with early stages of DR. A total of 194 plasma samples were collected from patients with type 2 DM and DR (moderate to proliferative (PDR) or control (no or mild DR) matched for age, gender, diabetes duration, HbA1c, and hypertension. Untargeted lipidomic and metabolomic approaches were performed. Partial-least square methods were used to analyze the datasets. Levels of 69 metabolites and 85 lipid species were found to be significantly different in the plasma of DR patients versus controls. Metabolite set enrichment analysis indicated that pathways such as metabolism of branched-chain amino acids (methylglutaryl carnitine p = 0.004), the kynurenine pathway (tryptophan p < 0.001), and microbiota metabolism (p-Cresol sulfate p = 0.004) were among the most enriched deregulated pathways in the DR group. Moreover, Glucose-6-phosphate (p = 0.001) and N-methyl-glutamate (p < 0.001) were upregulated in DR. Subgroup analyses identified a specific signature associated with PDR, macular oedema, and DR associated with chronic kidney disease. Phosphatidylcholines (PCs) were dysregulated, with an increase of alkyl-PCs (PC O-42:5 p < 0.001) in DR, while non-ether PCs (PC 14:0-16:1, p < 0.001; PC 18:2-14:0, p < 0.001) were decreased in the DR group. Through an unbiased multiomics approach, we identified metabolites and lipid species that interestingly discriminate patients with or without DR. These features could be a research basis to identify new potential plasma biomarkers to promote 3P medicine.

Medullary sponge kidney: unusual finding in kidney transplant recipient

Background

Medullary sponge kidney is generally considered a benign condition, gold standard for the diagnosis is urography but it has almost been replaced by UroCT that did not present the same sensibility. Although it is really rare, our sonography’s findings were consistent with medullary sponge kidney in the transplanted kidneys.

Case presentation

A 45-year-old woman with a long history of double-kidney transplantation complained of frequent urinary tract infections, a history of vague loin pain and came to our attention for sonography follow-up. Her kidney function was normal, we did not find signs of infections in the transplanted kidneys and urinary findings were normal. Curiously, the transplanted kidneys came from a newborn and the patient received a double-kidney transplantation in order to guarantee a satisfactory renal function.

Conclusions

Despite a long history of kidney transplantation, genetic disease should not be forgotten when symptoms and images recall to specific inherited alterations. Sonography has to be considered in diagnostic path of kidney cystic disease.

Diagnostic de l’embolie pulmonaire dans le contexte de la grossesse

Les problématiques posées par la prise en charge de la femme enceinte suspecte d’embolie pulmonaire (EP) aux urgences sont multiples. Les modifications physiologiques au cours de la grossesse majorent les sollicitations médicales pour des tableaux de douleur thoracique, de dyspnée, de malaise… En parallèle, ces manifestations aux cours de la grossesse peuvent se confondre avec les éléments évocateurs d’une EP et interférer sur nos capacités d’appréciation de sa probabilité. Enfin, l’élévation physiologique des D-dimères et le taux d’imageries thoraciques non conclusives complexifient la démarche diagnostique. C’est pourtant dans le contexte de la grossesse qu’il est particulièrement souhaitable de ne pas manquer un diagnostic d’EP, tout en évitant d’exposer inutilement la patiente et son foetus à l’imagerie thoracique. Pour aider dans les prises de décision, deux stratégies ont été validées dans le contexte de la grossesse. La première repose sur le score de Genève, incluant la réalisation d’une échographie de compression proximale chez les patientes à probabilité forte ou ayant un D-dimère supérieur à 500 μg/L. La seconde repose sur l’algorithme YEARS, avec réalisation d’une échographie uniquement chez les patientes ayant des symptômes évocateurs d’une thrombose veineuse des membres inférieurs associée, puis un dosage des D-dimères avec un seuil à 500 ou 1 000 μg/L en fonction de la probabilité clinique. La fiabilité de ces deux stratégies a été démontrée. La première stratégie présente l’avantage de ne reposer que sur des données objectives, et la deuxième de reposer le seuil décisionnel à 1 000 μg/L chez les patientes n’ayant aucun des critères YEARS.

MR Brain Screening in ADPKD Patients : To Screen or not to Screen?

BACKGROUND

Adult polycystic kidney disease (ADPKD) still represents a major cause of renal failure and intracranial aneurisms (IA) have a higher prevalence in ADPKD than in the general population. Current guidelines suggest performing brain MRI only in the subjects with a positive familiar history of IAs or subarachnoid hemorrhage (SAH). This is a retrospective case-control analysis to evaluate the usefulness of a MR screening program in ADPKD patients.

METHODS

We retrospectively analyzed all ADPKD patients followed in our outpatient clinic between 2016 and 2019 who underwent a brain MRI screening. We evaluated the presence of IAs and others brain abnormalities and compared our results with a non-ADPKD population (n = 300). We performed univariate and multivariate regression analysis to evaluate if general and demographic features, laboratory findings, clinical parameters and genetic test results correlated with IAs or other brain abnormalities presence.

RESULTS

Among the patients evaluated 17 out of 156 (13.6%) ADPKD patients had IAs, compared to 16 out of 300 (5.3%) non-ADPKD controls (p < 0.005). Considering ADPKD patients presenting IAs, 12 (70.6%) had no family history for IAs or SAH. Genetic analysis was available for 97 patients: in the sub-population with IAs, 13 (76.5%) presented a PKD1 mutation and none a PKD2 mutation. We found that arachnoid cysts (AC) (p < 0.001) and arterial anatomical variants (p < 0.04) were significantly more frequent in ADPKD patients.

CONCLUSION

In our population ADPKD patients showed a higher prevalence of IAs, AC and arterial variants compared to non-ADPKD. Most of the IAs were found in patients presenting a PKD1 mutation. We found a significant number of alterations even in those patients without a family history of IAs or SAH. The practice of submitting only patients with familial IAs or kidney transplantation candidates to MRI scan should be re-evaluated.

Mediterranean diet adherence in pregnant women: results of a survey in North East of Italy

Background

In literature, few studies evaluated Mediterranean diet (MD) adherence in pregnant women, so we decided to conduct a survey to analyze MD and healthy habits in pregnant women living in North East of Italy, in 2018.

Methods

In our monocentric observational study, we enrolled &gt;18 years pregnant women (2nd-3rd trimester) to evaluate MD adherence through “PREDIMED” validated questionnaire. Based on previous studies on MD score, women were classified into High-MD adherence (score &gt;8; range 0-14) and low-MD adherence group (score ≤ 8). Comparisons between groups were performed using a t-test, Wilcoxon-Mann-Whitney test, chi square test and regression models as appropriate. We also investigated BMI (body mass index) and healthy habits before and during pregnancy.

Results

We analyzed 113 questionnaires and MD score, ranging from 3 to 13, had a mean value of 8.04 (SD 1.95), with low MD adherence in 63% (71) of our sample. Women (mean age 32 years; min 22- max 43; SD 1.95) were mostly employed (95; 84%) and alcohol consumers before pregnancy 79 (70%), especially wine 53 (47%). 5 (4%) didn't quit smoking while pregnant. Comparing BMI data before and during pregnancy to international recommendations, we found inadequate weight gain for each BMI category (100% in underweight, 70.7% in normal weight, 35% in overweight, 50% in obese range). Age was associated with MD adherence (β 0.11; 95%CI 0.04-0.17). Employment was also positively associated with higher MD values (p 0.002). Wine assumption before pregnancy was statistically significant associated with high MD group (p 0.0334).

Conclusions

In our study we found MD adherence levels lower than expected and an inadequate weight gain during pregnancy. MD seems also to be age and employment-related. Wine consumption before pregnancy and its positive association with MD need to be further analyzed.

Key messages

Mediterranean Diet adherence among pregnant women studied is not high and weight gain is frequently inadequate. Age and employment status might influence MD adherence in pregnancy.

Legionella and agar cultures in healthcare facilities waters: a monitoring study in North-East Italy

Background

Water healthiness is fundamental in medical facilities. Monitoring Legionella spp. and agar cultures concentration is therefore very important. This study looks into these parameters to examine possible criticalities that could need interventions.

Methods

We collected 399 Legionella and 82 agar cultures withdrawals between November 2019 and February 2020 from 157 detection points (like taps and showers) in 31 structures of four health districts. Withdrawals referred to the 4 quarters of year 2019 (t1, t2, t3, t4). Legionella values were expressed in colony forming units (CFU)/l; agar cultures in CFU/ml. We performed a non-parametric analysis to compare mean values between districts. We used the statistical software package SAS version 9.4 for Windows, setting the significance level at α = 0.05.

Results

45% of structures presented at least one positive withdrawal for Legionella (in six we found positivity in more than 1 quarter). Concerning Legionella concentration, we found significant difference between districts in t2 (p = 0.012) and between wards of one district in t3 (p &lt; 0.05). We observed agar positive values in 11 structures (in four cases in more than 1 quarter). In t4 we found a very significant difference (p &lt; 0.0001) between agar values in the four districts, while in t3 we observed a non significant association (p = 0.067). In t3 we found a significant difference for agar values between wards of one district (p = 0.025). We finally considered the simultaneous presence or absence of Legionella and agar positivities: without considering quarters division, we observed accordance (both present or both absent) in 60 detection points, while in 34 points we didn't find it.

Conclusions

Data provided by this study show that Legionella is rather present in our districts, revealing an association with concentration of CFU in agar. Disinfecting operations should be implemented considering the differences between districts to provide a safe water in every ward.

Key messages

Water quality monitoring in healthcare facilities is fundamental to provide a safe and healthy environment. Legionella spp. and agar cultures concentrations depend by quarter and spot considered; focused operations should be taken into account to improve disinfection quality.

What is the healthcare carbon footprint? A collaborative analysis of current literature

Background

Climate change (CC) is a public health (PH) issue of growing concern. Health care systems in every country have a significant impact in terms of greenhouse gas emissions (GHGE) causing global warming, but there seems to be a general lack of knowledge about this. As members of the junior study group on CC and PH of the Italian Society of Hygiene (SItI), we launched a project of shared education and literature research about the carbon footprint of healthcare (HCCF). We believe such an effort to be useful in spreading awareness and promoting change both in clinical practice, health care management and at policymaking level.

Objectives

To answer these questions: What is the estimated national and global HCCF?

Which activities contribute to HCCF?

What are the possible actions and policies to reduce HCCF while providing universal health care of good quality in all countries?

From Dec 2019 to Feb 2020 we used databases and backward citation searching to retrieve references which we split among individuals to process, then we shared summaries of the material with the group.

Results

HCCF makes about 4.4% of all GHGE, with important variations among countries. We found estimates on emissions for various activities (e.g. operating theatres) and items (e.g. inhalers), as well as proposed solutions for practitioners, managers, manufacturers and policymakers (e.g. low-impact technologies, advocacy, health promotion to reduce healthcare volumes).

Conclusions

HCCF is complex, attributable to many components and amenable to mitigation through actions at all levels, with additional benefits for efficiency and public health. These conclusions are relevant for all countries as they imply joint international and transversal efforts throughout the world's health care sector.

Key messages

Current data and analysis, available for several services and in many countries, show healthcare carbon footprint is significant. Emissions from health sector can be reduced while granting universal healthcare globally.

Glucagon-like Peptide 1 Receptor Agonists, Diabetic Retinopathy and Angiogenesis: The AngioSafe Type 2 Diabetes Study

AIMS

Recent trials provide conflicting results on the association between glucagon-like peptide 1 receptor agonists (GLP-1RA) and diabetic retinopathy (DR). The aim of the AngioSafe type 2 diabetes (T2D) study was to determine the role of GLP-1RA in angiogenesis using clinical and preclinical models.

METHODS

We performed two studies in humans. In study 1, we investigated the effect of GLP-1RA exposure from T2D diagnosis on the severity of DR, as diagnosed with retinal imaging (fundus photography). In study 2, a randomized 4-week trial, we assessed the effect of liraglutide on circulating hematopoietic progenitor cells (HPCs), and angio-miRNAs.We then studied the experimental effect of Exendin-4, on key steps of angiogenesis: in vitro on human endothelial cell proliferation, survival and three-dimensional vascular morphogenesis; and in vivo on ischemia-induced neovascularization of the retina in mice.

RESULTS

In the cohort of 3154 T2D patients, 10% displayed severe DR. In multivariate analysis, sex, disease duration, glycated hemoglobin (HbA1c), micro- and macroangiopathy, insulin therapy and hypertension remained strongly associated with severe DR, while no association was found with GLP-1RA exposure (o 1.139 [0.800-1.622], P = .47). We further showed no effect of liraglutide on HPCs, and angio-miRNAs. In vitro, we demonstrated that exendin-4 had no effect on proliferation and survival of human endothelial cells, no effect on total length and number of capillaries. Finally, in vivo, we showed that exendin-4 did not exert any negative effect on retinal neovascularization.

CONCLUSIONS

The AngioSafe T2D studies provide experimental and clinical data confirming no effect of GLP-1RA on angiogenesis and no association between GLP-1 exposure and severe DR.

Customer satisfaction survey in Friuli Venezia Giulia university canteens

Background

Customer satisfaction represents an innovative approach to measure strengths and weaknesses of an organization and is useful for a customer-focused management and culture development. Our survey’s aim was to investigate perceived quality and needs of customers in the university canteen sector.

Methods

Between April and June 2018, an anonymous online questionnaire was distributed by “agenzia regionale per il diritto agli studi superiori” (ARDISS) among university students in Friuli Venezia Giulia, Italy. The questions covered 3 thematic areas: attendance of the service, quality of services and opinions on new initiatives. Furthermore, there was an open question to collect students’ suggestions or proposals to improve the service. Satisfaction about the service was evaluated through five topics: environments, hygiene, staff, meals, global satisfaction. Collected data were analyzed with descriptive, univariate and multivariate analyses. Statistical analyses were performed using 9.4 SAS software.

Results

Response rate was 20.5% (1933/9404). Multiple logistic regression analyses showed a difference in meal choice (entire vs reduced) between institutional canteen and partner cafeterias users (p &lt; 0.0001) and that male (p &lt; 0.0001) and foreign students (p 0.0003) prefer entire meal instead of reduced. Percentage of students who prefer entire meal is reduced (p &lt; 0.0001) if price range increases. Univariate and multivariate analyses showed that high quality perception is associated with lower price range and no suggestions about food and environments (p &lt; 0.0001); multivariate analyses also showed an association between high quality perception and high canteen attendance (p &lt; 0.05).

Conclusions

The survey showed an association between meal choice and students’ profile and between perceived quality and customer’s features. These data and further analyses may help to select areas where an intervention could improve service quality and, therefore, customer satisfaction.

Key messages

Customer satisfaction is an important tool to measure and improve university canteen service quality. These results helped us to identify services’ strengths and weaknesses according to students’ opinions; this could be useful to select improvement areas.

Knowledge and attitudes about Human Papillomavirus and its prevention in Italian students, 2018

Background

Human Papillomavirus (HPV) infections show an estimated prevalence of 290 millions of cases worldwide, being the most common viral infection related to the reproductive tract and the main cause of cervical cancer. Being HPV vaccination currently recommended for both genders, we assessed knowledge and attitudes regarding HPV prevention among high school students in Udine, Northern Italy.

Methods

Between April and May 2018, a sexual and reproductive health anonymous questionnaire was proposed to first-year students in five academic, technical and vocational upper secondary schools of Udine. In particular, students were asked about HPV related diseases, whether they were vaccinated against HPV and how that decision was taken. Data were analyzed by school type and gender using Chi Square Test with α = 0.05.

Results

A total of 747 questionnaires were collected from 990 students; both genders had a mean age of 14.8±0.9 years, 59% of respondents were males. Technical high school students were 42% of the sample, while 30% came from vocational and 28% from academic high schools. Genital warts and cervical cancer were identified as HPV-related by 8% and 20% of students respectively, the latter more frequently in technical institutes (p = 0.0016) and in females (43% vs 13%, p &lt; 0.001). Almost 54% of students did not know if they were immunized against HPV; academic school students and females declared more frequently to have received at least one vaccine dose compared to others (p &lt; 0.001). Almost two thirds of respondents reported to have undergone vaccination due to a parental decision; parents discussed this choice more frequently with academic students (p = 0.0016) and females (22% vs 14%, p &lt; 0.001).

Conclusions

Girls and technical school students are more informed about HPV, while adherence to immunization schedules is higher in females and those attending academic school. Parents appear to create a supportive environment for females.

Key messages

The different level of knowledge by gender can be explained by past vaccination campaigns, mainly focused on girls, and by parental proactivity towards females. There is room for improvement in HPV-related knowledge and prevention among both adolescents in general and males in particular as they can play an important role to reduce the burden of HPV.

Facing climate change challenges: the Italian Public Health Residents response

Background

Climate change (CC) is one of the most important global issues, and exerts a strong impact on public health (PH). Correlation between CC and PH is a matter of concern in the whole scientific community and requires an interdisciplinary approach. Nevertheless, the need to take action on CC sometimes contrasts with national and local policies, involved professionals’ training and citizens’ education. In order to face these challenges, the Italian network of public health residents “Consulta Specializzandi” of the Italian Society of Hygiene, Preventive Medicine and Public Health (SItI) decided to create a specific working group.

Objectives

Main objectives are education of PH residents and practitioners on CC, argument disclosure among the SItI and creation of interdisciplinary networks to promote and extend group activities. Secondary objective is development of a study to identify the gap between scientific evidence, recommendations and guidelines, and the European, national and local policies, with the aim of promoting bottom-up researches and good practices in CC management.

Results

The group was created in January 2019; activities started in March. Firstly we defined priorities and work mode. Then we analyzed scientific evidence and promoted self-training on the link between environment and CC and on the impact of CC on individual and public health. Finally, through attendance at workshops and scientific events, we began to train other PH residents and practitioners and started to create networks with other scientific societies, research centers and foreign academies, in order to promote international research, advocacy and disclosure between different institutions regarding the relationship between CC and PH.

Conclusions

The group has already partially achieved its main objectives, especially increasing awareness and training in CC and related issues. Further activities will permit to strength interdisciplinary networks and to move to secondary objectives.

Key messages

CC severely impacts society. Yet there is no widespread feeling of urgency to act towards its causes and consequences. A change in mindset is mandatory, from individual citizens to decision makers. PH residents and practitioners must be the main actors in training and education, advocacy, disclosure and network creation in CC research and management.

P5019Derivation and validation of a new probability score in pulmonary embolism suspicion allowing safely reduction of imaging testing: PEPS (Pulmonary Embolism Probability Score)

Background

In pulmonary embolism (PE) suspicion, several strategies based on clinical criteria and D-dimer (Dd) measurement have been developed in order to reduce resource utilization. However, they used different clinical probability (CP) assessment methods limiting their combination.

Purpose

To develop and validate a unique probability score integrating most of previous proposals to allow safely reduction of imaging testing.

Methods

4 CP levels were previously defined in order to obtain a false negative rate <1.9%: 1) without Dd test: very low CP (PE prevalence <1.9%), 2) with Dd <1000 μg/L: low CP (<15%), 3) with Dd <500 or age x10μg/L: moderate CP (<60%) and 4) precluding PE exclusion on Dd: high CP. We used individual data from 4 prospective cohorts of suspected PE patients in Europe and America (n=11 066) for derivation and internal validation. The variables significantly associated with PE in univariate analysis were included in a multivariate logistic regression model. Points were assigned according to the regression coefficients. The score was validated in two external independent cohorts (n=1554, n=1669).

Results

PEPS comprised 13 variables: age <50 years (−2), age 50–64 years (−1), heart rate <80 beats/min (−1), chronic lung disease (−1), chest pain and recent dyspnea (+1), syncope (+1), male sex (+1), previous venous thromboembolism (+2), medical or orthopaedic immobilization (+2), estrogenic treatment (+2), oxygen saturation <95% (+3), unilateral lower limb pain (+3) and PE is the most likely diagnosis (+ 5). The rates of false negative and avoidable imaging tests if the PEPS strategy would have been applied were 0.6% [95% CI: 0.3–1.1] and 22.7% [20.2–25.3] in the first external validation cohort, and 0.85 [0.5–1.45] and 26.6% [23.5–29.9] in the second one. Applied retrospectively, PEPS strategy compared favourably with other strategies and combinations.

Derivation Int. validation Ext. validation 1 Ext. validation 2 nPE/N % [95% CI] nPE/N % [95% CI] nPE/N % [95% CI] nPE/N % [95% CI] TOTAL 615/5588: 11.0% [10.2–11.9] 432/3726: 11.6% [10.6–12.7] 327/1546: 21.2% [19.2–23.2] 196/1669: 11.7% [10.3–13.4] Very low CP PEPS<0 16/1445: 1.1% [0.7–1.8] 16/946: 1.7% [1.0–2.7] 3/118: 2.5% [0.7–6.8] 5/347: 1.4% [0.6–3.3] Low CP 0≤PEPS<5 127/2620: 4.9% [4.1–5.7] 106/1805: 5.9% [4.9–7.1] 49/611: 8.0% [6.1–10.4] 61/647: 7.2% [5.7–9.1] Moderate CP 5≤PEPS<12 347/1334: 26.0% [23.7–28.4] 243/867: 28.0% [25.1–31.1] 206/715: 28.8% [25.6–32.2] 107/430: 24.9% [21.0–29.2] High CP 12≤PEPS 125/179:69.8% [62.8–76.1] 67/108: 62.0% [52.6–70.6] 69/102: 67.7% [58.1–76.2] 23/45: 51.1% [37.0–65.0] AUC 0.84 [0.83–0.86] 0.82 [0.80–0.84] 0.79 [0.76–0.82] 0.77 [0.74–0.80] CP: Clinical probability; PEPS: Pulmonary Embolism Probability Score.

Conclusions

A strategy based on the proposed score may lead to a safely substantial reduction of imaging testing. It should now be tested in an outcome interventional study.

[Diagnosis of pulmonary embolism]

The diagnosis of pulmonary embolism (PE) is nowadays based on the sequential use of several diagnostic tests rather than on a single test. These diagnostic strategies are safe and have been prospectively validated. The first step after identifying patients with suspicion of PE is to establish the pre-test clinical probability. Several scores are available in order to make a standardised and reproducible assessment of the clinical probability, and therefore represent precious diagnostic tools. Indeed, clinical probability guides further investigations. Indeed, in patients with a low or an intermediate clinical probability or an "unlikely" probability, PE can be safely ruled out by negative D-dimers in approximately one third of outpatients without additional imaging. In case of positive D-dimers and a high clinical probability or a "likely" clinical probability, CT pulmonary angiography is now the recommended imaging technique. However, lower limb venous compression ultrasound and ventilation/perfusion scans remain useful in patients with contra-indications to CT, mainly those with renal insufficiency. Finally, some novel diagnostic tests seem promising. For example, V/Q SPECT has arisen as a highly accurate test and a potential alternative to CTPA. However, prospective management outcome studies are still lacking and are warranted before its implementation in routine clinical practice.

Basin-scale analysis of the geomorphic effectiveness of flash floods: A study in the northern Apennines (Italy)

Large floods may produce remarkable channel changes, which determine damages and casualties in inhabited areas. However, our knowledge of such processes remains poor, as is our capability to predict them. This study analyses the geomorphic response of the Nure River (northern Italy) and nine tributaries to a high-magnitude flood that occurred in September 2015. The adopted multi-disciplinary approach encompassed: (i) hydrological and hydraulic analysis; (ii) analysis of sediment delivery to the stream network by means of landslides mapping; (iii) assessment of morphological modifications of the channels, including both channel width and bed elevation changes. The spatial distribution of rainfall showed that the largest rainfall amounts occur in the upper portions of the catchment, with cumulative rainfall reaching 300 mm in 12 h, and recurrence intervals exceeding 100-150 years. The unit peak discharge ranged between 5.2 and 25 m³ s^-1 km^-2. Channel widening was the most evident effect. In the tributaries, the ratio between post-flood and pre-flood channel width averaged 3.3, with a maximum approaching 20. Widening was associated with channel aggradation up to 1.5 m and removal of riparian vegetation. New islands formed due to the fragmentation of the former floodplain. In the Nure River, the average width ratio was 1.7, and here widening occurred mainly at the expenses of islands. Bed level dynamics in the Nure were varied, including aggradation, incision, and overall stability. The flood geomorphic effectiveness was more pronounced in the middle-higher portions of the basin. Planimetric and elevation changes were well correlated. Regression analysis of the relationship between widening and morphological/ hydraulic controlling factors indicated that unit stream power and confinement index were the most relevant variables. The study provides useful insights for river management, especially with regard to the proportion of the valley floor subject to erosion and/or deposition during large events.

Age-adjusted D-dimer to rule out deep vein thrombosis: findings from the PALLADIO algorithm

Essentials The accuracy of the age-adjusted D-dimer in suspected venous thromboembolism is still debated. We assessed the performance of age-adjusted D-dimer combined with the PALLADIO algorithm. The age-adjusted threshold can reduce the need for imaging tests compared to the fixed cut-off. The safety of this approach should be confirmed in large management studies.

SUMMARY

Background Age-adjusted D-dimer has been proposed to increase specificity for the diagnosis of venous thromboembolism (VTE). However, the accuracy of this threshold has been recently questioned. Objectives To assess the diagnostic performance of age-adjusted D-dimer combined with clinical pretest probability (PTP) in patients with suspected deep vein thrombosis (DVT). Methods PALLADIO (NCT01412242) was a multicenter management study that validated a new diagnostic algorithm, incorporating PTP, D-dimer (using the manufacturer's cut-off) and limited or extended compression ultrasonography (CUS) in outpatients with clinically suspected DVT. Patients with unlikely PTP and negative D-dimer had DVT ruled out without further testing (group 1); patients with likely PTP or positive D-dimer underwent limited CUS (group 2); patients with likely PTP and positive D-dimer underwent extended CUS (group 3). Patients with DVT ruled out at baseline had a 3-month follow-up. In this post-hoc analysis we evaluated age-adjusted D-dimer cut-off (defined as age times 10 μg L-1 , or age times 5 μg L-1 for D-dimers with a lower manufacturer's cut-off, in patients > 50 years). Results In total, 1162 patients were enrolled. At initial visit, DVT was detected in 4.0% of patients in group 2 and 53.0% in group 3. The age-adjusted D-dimer, compared with the fixed cut-off, resulted in 5.1% (95% CI, 4.0-6.5%) reduction of CUS. The incidence of symptomatic VTE during follow-up was: 0.24% (95% CI, 0.04-1.37) in group 1; 1.12% (95% CI, 0.44-2.85) in group 2; and 1.89% (95% CI, 0.64-5.40) in group 3. Conclusions The PALLADIO algorithm using age-adjusted D-dimer slightly decreased the number of required imaging tests, but this approach should be confirmed in large management studies.

Ruling out pulmonary embolism across different subgroups of patients and healthcare settings: protocol for a systematic review and individual patient data meta-analysis (IPDMA)

BACKGROUND

Diagnosing pulmonary embolism in suspected patients is notoriously difficult as signs and symptoms are non-specific. Different diagnostic strategies have been developed, usually combining clinical probability assessment with D-dimer testing. However, their predictive performance differs across different healthcare settings, patient subgroups, and clinical presentation, which are currently not accounted for in the available diagnostic approaches.

METHODS

This is a protocol for a large diagnostic individual patient data meta-analysis (IPDMA) of currently available diagnostic studies in the field of pulmonary embolism. We searched MEDLINE (search date January 1, 1995, till August 25, 2016) to retrieve all primary diagnostic studies that had evaluated diagnostic strategies for pulmonary embolism. Two authors independently screened titles, abstracts, and subsequently full-text articles for eligibility from 3145 individual studies. A total of 40 studies were deemed eligible for inclusion into our IPDMA set, and principal investigators from these studies were invited to participate in a meeting at the 2017 conference from the International Society on Thrombosis and Haemostasis. All authors agreed on data sharing and participation into this project. The process of data collection of available datasets as well as potential identification of additional new datasets based upon personal contacts and an updated search will be finalized early 2018. The aim is to evaluate diagnostic strategies across three research domains: (i) the optimal diagnostic approach for different healthcare settings, (ii) influence of comorbidity on the predictive performance of each diagnostic strategy, and (iii) optimize and tailor the efficiency and safety of ruling out PE across a broad spectrum of patients with a new, patient-tailored clinical decision model that combines clinical items with quantitative D-dimer testing.

DISCUSSION

This pre-planned individual patient data meta-analysis aims to contribute in resolving remaining diagnostic challenges of time-efficient diagnosis of pulmonary embolism by tailoring available diagnostic strategies for different healthcare settings and comorbidity.

SYSTEMATIC REVIEW REGISTRATION

Prospero trial registration: ID 89366.

Long-term outcomes of elderly patients with CYP2C9 and VKORC1 variants treated with vitamin K antagonists

Essentials The long-term effects of VKORC1 and CYP2C9 variants on clinical outcomes remains unclear. We followed 774 patients ≥65 years with venous thromboembolism for a median duration of 30 months. Patients with CYP2C9 variants are at increased risk of death and non-major bleeding. Patients with genetic variants have a slightly lower anticoagulation quality only.

SUMMARY

Background The long-term effect of polymorphisms of the vitamin K-epoxide reductase (VKORC1) and the cytochrome P450 enzyme gene (CYP2C9) on clinical outcomes remains unclear. Objectives We examined the association between CYP2C9/VKORC1 variants and long-term clinical outcomes in a prospective cohort study of elderly patients treated with vitamin K antagonists for venous thromboembolism (VTE). Methods We followed 774 consecutive patients aged ≥ 65 years with acute VTE from nine Swiss hospitals for a median duration of 30 months. The median duration of initial anticoagulant treatment was 9.4 months. The primary outcome was the time to any clinical event (i.e. the composite endpoint of overall mortality, major and non-major bleeding, and recurrent VTE. Results Overall, 604 (78%) patients had a CYP2C9 or VKORC1 variant. Three hundred and thirty-four patients (43.2%) had any clinical event, 119 (15.4%) died, 100 (12.9%) had major and 167 (21.6%) non-major bleeding, and 100 had (12.9%) recurrent VTE. After adjustment, CYP2C9 (but not VKORC1) variants were associated with any clinical event (hazard ratio [HR], 1.34; 95% confidence interval [CI], 1.08-1.66), death (HR, 1.74; 95% CI, 1.19-2.52) and clinically relevant non-major bleeding (sub-hazard ratio [SHR], 1.39; 95% CI, 1.02-1.89), but not with major bleeding (SHR, 1.03; 95% CI, 0.69-1.55) or recurrent VTE (SHR, 0.95; 95% CI, 0.62-1.44). Patients with genetic variants had a slightly lower anticoagulation quality. Conclusions CYP2C9 was associated with long-term overall mortality and non-major bleeding. Although genetic variants were associated with a slightly lower anticoagulation quality, there was no relationship between genetic variants and major bleeding or VTE recurrence.

Treatment options for severe pulmonary embolism during pregnancy and the postpartum period: a systematic review

Essentials The evidence on how to manage life-threatening pregnancy-related pulmonary embolism (PE) is scarce. We systematically reviewed all available cases of (sub)massive PE until December 2016. Thrombolysis in such severe PE was associated with a high maternal survival (94%). The major bleeding risk was much greater in the postpartum (58%) than antepartum period (18%).

SUMMARY

Background Massive pulmonary embolism (PE) during pregnancy or the postpartum period is a rare but dramatic event. Our aim was to systematically review the evidence to guide its management. Methods We searched Pubmed, Embase, conference proceedings and the RIETE registry for published cases of severe (submassive/massive) PE treated with thrombolysis, percutaneous or surgical thrombectomy and/or extracorporeal membrane oxygenation (ECMO), occurring during pregnancy or within 6 weeks of delivery. Main outcomes were maternal survival and major bleeding, premature delivery, and fetal survival and bleeding. Results We found 127 cases of severe PE (at least 83% massive; 23% with cardiac arrest) treated with at least one modality. Among 83 women with thrombolysis, survival was 94% (95% CI, 86-98). The risk of major bleeding was 17.5% during pregnancy and 58.3% in the postpartum period, mainly because of severe postpartum hemorrhages. Fetal deaths possibly related to PE or its treatment occurred in 12.0% of cases treated during pregnancy. Among 36 women with surgical thrombectomy, maternal survival and risk of major bleeding were 86.1% (95% CI, 71-95) and 20.0%, with fetal deaths possibly related to surgery in 20.0%. About half of severe postpartum PEs occurred within 24 h of delivery. Conclusions Published cases of thrombolysis for massive PE during pregnancy and the postpartum period suggest a high maternal and fetal survival (94% and 88%). In the postpartum period, given the high risk of major bleeding with thrombolysis, other therapeutic options (catheter [or surgical] thrombectomy, ECMO) may be considered if available.

Assessing clinical probability of pulmonary embolism: prospective validation of the simplified Geneva score

Essentials The simplified Geneva score allows easier pretest probability assessment of pulmonary embolism (PE). We prospectively validated this score in the ADJUST-PE management outcome study. The study shows that it is safe to manage patients with suspected PE according to this score. The simplified Geneva score is now ready for use in routine clinical practice.

SUMMARY

Background Pretest probability assessment by a clinical prediction rule (CPR) is an important step in the management of patients with suspected pulmonary embolism (PE). A limitation to the use of CPRs is that their constitutive variables and corresponding number of points are difficult to memorize. A simplified version of the Geneva score (i.e. attributing one point to each variable) has been proposed but never been prospectively validated. Aims Prospective validation of the simplified Geneva score (SGS) and comparison with the previous version of the Geneva score (GS). Methods In the ADJUST-PE study, which had the primary aim of validating the age-adjusted D-dimer cut-off, the SGS was prospectively used to determine the pretest probability in a subsample of 1621 study patients. Results Overall, PE was confirmed in 294 (18.1%) patients. Using the SGS, 608 (37.5%), 980 (60.5%) and 33 (2%) were classified as having a low, intermediate and high clinical probability. Corresponding prevalences of PE were 9.7%, 22.4% and 45.5%; 490 (30.1%) patients with low or intermediate probability had a D-dimer level below 500 μg L-1 and 653 (41.1%) had a negative D-dimer test according to the age-adjusted cut-off. Using the GS, the figures were 491(30.9%) and 650 (40.9%). None of the patients considered as not having PE based on a low or intermediate SGS and negative D-dimer had a recurrent thromboembolic event during the 3-month follow-up. Conclusions The use of SGS has similar efficiency and safety to the GS in excluding PE in association with the D-dimer test.

Safety of multidetector computed tomography pulmonary angiography to exclude pulmonary embolism in patients with a likely pretest clinical probability

Essentials Safety of computed tomography (CTPA) to exclude pulmonary embolism (PE) in all patients is debated. We analysed the outcome of PE-likely outpatients left untreated after negative CTPA alone. The 3-month venous thromboembolic risk in these patients was very low (0.6%; 95% CI 0.2-2.3). Multidetector CTPA alone safely excludes PE in patients with likely clinical probability.

SUMMARY

Background In patients with suspected pulmonary embolism (PE) classified as having a likely or high pretest clinical probability, the need to perform additional testing after a negative multidetector computed tomography pulmonary angiography (CTPA) finding remains a matter of debate. Objectives To assess the safety of excluding PE by CTPA without additional imaging in patients with a likely pretest probability of PE. Patients/Methods We retrospectively analyzed patients included in two multicenter management outcome studies that assessed diagnostic algorithms for PE diagnosis. Results Two thousand five hundred and twenty-two outpatients with suspected PE were available for analysis. Of these 2522 patients, 845 had a likely clinical probability as assessed by use of the simplified revised Geneva score. Of all of these patients, 314 had the diagnosis of PE excluded by a negative CTPA finding alone without additional testing, and were left without anticoagulant treatment and followed up for 3 months. Two patients presented with a venous thromboembolism (VTE) during follow-up. Therefore, the 3-month VTE risk in likely-probability patients after a negative CTPA finding alone was 2/314 (0.6%; 95% confidence interval [CI] 0.2-2.3%). Conclusions In outpatients with suspected PE and a likely clinical probability as assessed by use of the simplified revised Geneva score, CTPA alone seems to be able to safely exclude PE, with a low 3-month VTE rate, which is similar to the VTE rate following the gold standard, i.e. pulmonary angiography.

Diagnosis of acute pulmonary embolism

Advances in the management of patients with suspected pulmonary embolism (PE) have improved diagnostic accuracy and made management algorithms safer, easier to use, and well standardized. These diagnostic algorithms are mainly based on the assessment of clinical pretest probability, D-dimer measurement, and imaging tests-predominantly computed tomography pulmonary angiography. These diagnostic algorithms allow safe and cost-effective diagnosis for most patients with suspected PE. In this review, we summarize signs and symptoms of PE, current existing evidence for PE diagnosis, and focus on the challenge of diagnosing PE in special patient populations, such as pregnant women, or patients with a prior VTE. We also discuss novel imaging tests for PE diagnosis and highlight some of the additional challenges that might require adjustments to current diagnostic strategies, such as the reduced clinical suspicion threshold, resulting in a lower proportion of PE among suspected patients as well as the overdiagnosis of subsegmental PE.

Performance of the age-adjusted cut-off for D-dimer in patients with cancer and suspected pulmonary embolism

BACKGROUND

Cancer patients frequently present with suspected pulmonary embolism (PE). The D-dimer (DD) test is less useful in excluding PE in cancer patients due to the lower specificity. In the general population, the age-adjusted cutoff for DD combined with a clinical decision rule (CDR) improved specificity in the diagnosis of PE.

OBJECTIVES

To evaluate the safety and efficacy of the age-adjusted cutoff (defined as age∗10μg/L in patients >50years) combined with a CDR for the exclusion of PE in cancer patients.

METHODS

We conducted a prospective study to evaluate the age-adjusted cutoff in patients with suspected PE. Here we report a post-hoc analysis on the performance of the age-adjusted cutoff in patients with and without cancer. The primary outcome was the rate of venous thromboembolic events (VTE) during three-month follow-up.

RESULTS

Of 3324 patients with suspected PE, 429 (12.9%) patients had cancer. The prevalence of PE was 25.2% in cancer patients and 18% in patients without cancer (p<0.001). Among cancer patients with an unlikely CDR, 9.9% had a DD <500μg/L as compared with 19.7% using the age-adjusted cutoff. In patients without cancer, these rates were 30.1% and 41.9%. The proportion of cancer patients in whom PE could be excluded by CDR and DD doubled from 6.3% to 12.6%. No VTE occurred during three-month follow-up (failure rate 0.0% (95% CI 0.0-6.9%)).

CONCLUSION

Compared with the conventional cutoff, the age-adjusted D-dimer cutoff doubles the proportion of patients with cancer in whom PE can be safely excluded by CDR and DD without imaging.

Improving the diagnostic management of upper extremity deep vein thrombosis

Essentials The Constans score and D-dimer can rule out upper extremity deep vein thrombosis without imaging. We evaluated the performance of an extended Constans score and an age-adjusted D-dimer threshold. The extended Constans score did not increase the efficiency compared to the original score. Age-adjusted D-dimer testing safely increased the efficiency by 4%, but this needs validation.

SUMMARY

Background Among patients with clinically suspected upper extremity deep vein thrombosis (UEDVT), a clinical decision rule based on the Constans score combined with D-dimer testing can safely rule out the diagnosis without imaging in approximately one-fifth of patients. Objectives To evaluate the performance of the original Constans score, an extended Constans score and an age-adjusted D-dimer positivity threshold. Methods Data of 406 patients with suspected UEDVT previously enrolled in a multinational diagnostic management study were used. The discriminatory performance, calibration and diagnostic accuracy of the Constans score were evaluated. The Constans score was extended by selecting clinical variables that may have incremental value in detecting UEDVT, conditional on the original Constans score items. The performance of the Constans rule was evaluated in combination with fixed and age-adjusted D-dimer thresholds. Results The original Constans score showed good discriminatory performance (c-statistic, 0.81; 95% confidence interval [CI], 0.76-0.85). An extended Constans score with five additional clinical items improved discriminatory performance and calibration, but this did not translate into a higher efficiency in avoiding imaging tests. Compared with a fixed threshold, age-adjusted D-dimer testing increased the proportion of patients for whom imaging and anticoagulation could be withheld from 21% to 25% (gain, 3.7%; 95% CI, 2.3-6.0%). Conclusions The Constans score has good discriminatory performance in the diagnosis of UEDVT. Age-adjusted D-dimer testing is likely to safely increase the efficiency of the diagnostic algorithm, but this approach needs prospective validation.

Pre-pregnancy BMI, delivery BMI, gestational weight gain and the risk of postpartum venous thrombosis

OBJECTIVE

To characterize the risk of postpartum venous thromboembolism (VTE) associated with body-mass-index (BMI) in both pre-pregnancy and at delivery, and with gestational weight gain (GWG).

METHODS

In a population-based, case-control study, we identified all women in Washington State with ICD-9 codes for VTE in the postpartum period between 2003 and 2011. Controls were women without VTE in the postpartum period, matched by delivery year to cases. Pre-pregnancy BMI, delivery BMI, and covariates were abstracted from birth certificates. Adjusted logistic regression models separately estimated postpartum VTE risk associated with categories of BMI in pre-pregnancy and at delivery.

RESULTS

Cases (n=289) had a higher mean BMI than controls (n=4208) pre-pregnancy (29.9kg/m(2) and 26.3kg/m(2), respectively) and at delivery (34.8kg/m(2) vs. 31.4kg/m(2), respectively), with similar gestational weight gains. Compared with women with a normal pre-pregnancy BMI (18.5-24.9kg/m(2)), overweight (BMI 25-29.9kg/m(2)) and obese (BMI≥30kg/m(2)) women were at a 1.5-fold and 1.8-4 fold greater risk of postpartum VTE, respectively, with greatest risks in women with class III obesity (BMI≥40kg/m(2): OR 4.0, 95%CI 2.7-6.3). Observed associations of delivery BMI with postpartum VTE were less strong than those of pre-pregnancy BMI. Large weight gains during pregnancy (>22kg) also contributed to greater VTE risks (OR 1.5, 95%CI 1.0-2.2).

CONCLUSION

Maternal BMI is an important risk factor for postpartum VTE, grading from weak in overweight women to very strong in women with class III obesity. Care providers may prefer to use pre-pregnancy BMI, along gestational weight gain, when stratifying the risk of postpartum VTE at delivery.

Current management strategies and long-term clinical outcomes of upper extremity venous thrombosis

Essentials Few data exist on outcome of upper extremity deep and superficial vein thrombosis (UEDVT and UESVT). We followed 102 and 55 patients with UEDVT or UESVT, respectively, for a median of 3.5 years. Risk of recurrent venous thromboembolism was low in both diseases, and the mortality high. Postthrombotic symptoms were infrequent and cancer patients had a higher risk of recurrent VTE.

SUMMARY

Background There is scant information on the optimal management and clinical outcome of deep and superficial vein thrombosis of the upper extremity (UEDVT and UESVT). Objectives To explore treatment strategies and the incidence of recurrent venous thromboembolism (VTE), mortality, postthrombotic symptoms, and bleeding in patients with UEDVT and UESVT and to assess the prognosis of cancer patients with UEDVT. Patients/methods Follow-up of patients with UEDVT or UESVT, who were enrolled previously in a diagnostic management study. Results We followed 102 and 55 patients with UEDVT and UESVT, respectively, both for a median of 3.5 years. Anticoagulant treatment was started in 100 patients with UEDVT (98%) and in 40 (73%) with UESVT. Nine patients with UEDVT (9%) developed recurrent VTE, 26 (26%) died, 6 (8%) of 72 patients had moderate postthrombotic symptoms, and 5 (5%) experienced major bleeding. One patient with UESVT had a recurrent VTE, 18 (33%) died, none had moderate postthrombotic symptoms, and none had major bleeding. Of the cancer patients with UEDVT, 18% had recurrent VTE vs. 7.5% in non-cancer patients (adjusted hazard ratio 2.2, 95%CI 0.6-8.2). The survival rate was 50% in cancer patients with UEDVT vs. 60% in those without (adjusted HR 0.8, 95%CI 0.4-1.4). Conclusions The risk of recurrent VTE was low in patients with UEDVT, and negligible for UESVT. Mortality was high for both diseases. Postthrombotic symptoms were infrequent and mild. Anticoagulant therapy of UEDVT carried a substantial risk of major bleeding. Cancer patients had a significant risk of recurrent VTE.

Association between thyroid dysfunction and venous thromboembolism in the elderly: a prospective cohort study

BACKGROUND

Venous thromboembolism (VTE) and subclinical thyroid dysfunction (SCTD) are both common in elderly patients. SCTD has been related to a hypercoagulable state and an increased thromboembolic risk. However, prospective data on the relationship between SCTD and VTE are lacking.

OBJECTIVES

To investigate the relationship between SCTD and recurrent VTE (rVTE), all-cause mortality, and thrombophilic biomarkers. Patients Elderly patients with VTE were studied.

METHODS

In a prospective multicenter cohort, thyroid hormones and thrombophilic biomarkers were measured 1 year after acute VTE, as both may be influenced by acute thrombosis. We defined subclinical hypothyroidism (SHypo) as elevated thyroid-stimulating hormone (TSH) levels (4.50-19.99 mIU L(-1) ), and subclinical hyperthyroidism (SHyper) as TSH levels of < 0.45 mIU L(-1) , both with normal free thyroxine levels. Outcomes were incidence of rVTE and overall mortality during follow-up starting after the 1-year blood sampling.

RESULTS

Of 561 participants (58% with anticoagulation), 6% had SHypo and 5% had SHyper. After 20.8 months of mean follow-up, 9% developed rVTE and 10% died. The rVTE incidence rate was 7.2 (95% confidence interval [CI] 2.7-19.2) per 100 patient-years in SHypo participants, 0.0 (95% CI 0.0-7.6) in SHyper participants, and 5.9 (95% CI 4.4-7.8) in euthyroid participants. In multivariate analyses, the sub-hazard ratio for rVTE was 0.00 (95% CI 0.00-0.58) in SHyper participants and 1.50 (95% CI 0.52-4.34) in SHypo participants as compared with euthyroid participants, without increased levels of thrombophilic biomarkers. SHyper (hazard ratio [HR] 0.80, 95% CI 0.23-2.81) and SHypo (HR 0.99, 95% CI 0.30-3.29) were not associated with mortality.

CONCLUSION

In elderly patients, SHyper may be associated with lower rVTE risks. SHypo showed a non-statistically significant pattern of an association with rVTE, without increased mortality or differences in thrombophilic biomarkers.

Controversies in the diagnosis of venous thromboembolism

Over the last decades, important advances have been made in the diagnosis of venous thromboembolism (VTE). Current diagnostic strategies rely on the sequential use of non-invasive diagnostic tests, based on the pretest clinical probability of disease. Diagnostic tests include D-dimer measurement, leg vein compression ultrasonography, chest computed tomography pulmonary angiography, or ventilation perfusion (V/Q) lung scan. The safety and cost-effectiveness of these strategies have been extensively validated. They have been widely implemented in clinical practice and have replaced the historical gold standard diagnostic tests (venography and pulmonary angiography). However, new challenges arise, including a lower clinical suspicion threshold and concerns on potential over-diagnosis of VTE. Moreover, the diagnostic management remains suboptimal in many subgroups of patients with suspected VTE: patients with prior VTE, pregnant women, or elderly patients.

Cardiac biomarkers and clinical scores for risk stratification in elderly patients with non-high-risk pulmonary embolism

OBJECTIVE

To determine the prognostic accuracy of cardiac biomarkers alone and in combination with clinical scores in elderly patients with non-high-risk pulmonary embolism (PE).

DESIGN

Ancillary analysis of a Swiss multicentre prospective cohort study.

SUBJECTS

A total of 230 patients aged ≥65 years with non-high-risk PE.

MAIN OUTCOME MEASURES

The study end-point was a composite of PE-related complications, defined as PE-related death, recurrent venous thromboembolism or major bleeding during a follow-up of 30 days. The prognostic accuracy of the Pulmonary Embolism Severity Index (PESI), the Geneva Prognostic Score (GPS), the precursor of brain natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT) was determined using sensitivity, specificity, predictive values, receiver operating characteristic (ROC) curve analysis, logistic regression and reclassification statistics.

RESULTS

The overall complication rate during follow-up was 8.7%. hs-cTnT achieved the highest prognostic accuracy [area under the ROC curve: 0.75, 95% confidence interval (CI): 0.63-0.86, P < 0.001). At the predefined cut-off values, the negative predictive values of the biomarkers were above 95%. For levels above the cut-off, the risk of complications increased fivefold for hs-cTnT [odds ratio (OR): 5.22, 95% CI: 1.49-18.25] and 14-fold for NT-proBNP (OR: 14.21, 95% CI: 1.73-116.93) after adjustment for both clinical scores and renal function. Reclassification statistics indicated that adding hs-cTnT to the GPS or the PESI significantly improved the prognostic accuracy of both clinical scores.

CONCLUSION

In elderly patients with nonmassive PE, NT-proBNP or hs-cTnT could be an adequate alternative to clinical scores for identifying low-risk individuals suitable for outpatient management.

Is it useful to also image the asymptomatic leg in patients with suspected deep vein thrombosis?

BACKGROUND

Venous ultrasonography is the cornerstone of the diagnostic work-up in patients with suspected deep vein thrombosis (DVT). Significant variations exist in clinical practice between centers and/or countries, e.g. proximal vs. whole-leg ultrasound, serial tests vs. single test, and combination with clinical probability and D-dimer testing. Fewer data exist on the need for bilateral leg imaging.

OBJECTIVES

To assess the yield of bilateral leg ultrasonography in patients with suspected DVT.

PATIENTS AND METHODS

This was a retrospective cohort study of consecutive patients with clinically suspected DVT. A single whole-leg ultrasound scan was performed in all patients. We extracted information on demographics, risk factors, clinical signs, pretest probability, side of clinical suspicion, and ultrasound results.

RESULTS AND CONCLUSIONS

Among the 2804 included patients, 609 (21.8%) patients had a positive ultrasound finding. A total of 20 patients (0.8%; 95% confidence interval [CI] 0.5-1.2%) had a thrombus diagnosed in both the symptomatic leg and asymptomatic leg. Moreover, five patients (0.2%; 95% CI 0.1-0.5%) did not have a thrombus in the symptomatic leg but had a thrombus in the asymptomatic leg. Two of 2540 patients with unilateral symptoms had no proximal DVT in the symptomatic leg and a proximal DVT in the asymptomatic leg (0.08%; 95% CI 0.0-0.3%). In summary, systematic imaging of both legs in patients with suspected DVT has a very low yield, and therefore does not appear to be justified.

Physical activity and risk of bleeding in elderly patients taking anticoagulants

BACKGROUND

Although the possibility of bleeding during anticoagulant treatment may limit patients from taking part in physical activity, the association between physical activity and anticoagulation-related bleeding is uncertain.

OBJECTIVES

To determine whether physical activity is associated with bleeding in elderly patients taking anticoagulants.

PATIENTS/METHODS

In a prospective multicenter cohort study of 988 patients aged ≥ 65 years receiving anticoagulants for venous thromboembolism, we assessed patients' self-reported physical activity level. The primary outcome was the time to a first major bleeding, defined as fatal bleeding, symptomatic bleeding in a critical site, or bleeding causing a fall in hemoglobin or leading to transfusions. The secondary outcome was the time to a first clinically relevant non-major bleeding. We examined the association between physical activity level and time to a first bleeding by using competing risk regression, accounting for death as a competing event. We adjusted for known bleeding risk factors and anticoagulation as a time-varying covariate.

RESULTS

During a mean follow-up of 22 months, patients with a low, moderate, and high physical activity level had an incidence of major bleeding of 11.6, 6.3, and 3.1 events per 100 patient-years and an incidence of clinically relevant non-major bleeding of 14.0, 10.3, and 7.7 events per 100 patient-years, respectively. A high physical activity level was significantly associated with a lower risk of major bleeding (adjusted sub-hazard ratio 0.40, 95% confidence interval 0.22-0.72). There was no association between physical activity and non-major bleeding.

CONCLUSIONS

A high level of physical activity is associated with a decreased risk of major bleeding in elderly patients receiving anticoagulant therapy.

Racial and ethnic differences in the risk of postpartum venous thromboembolism: a population-based, case-control study

BACKGROUND

Venous thromboembolism (VTE) is a major contributor of maternal morbidity and mortality. Whether maternal race/ethnicity is associated with the risk of postpartum VTE remains unclear.

METHODS AND RESULTS

We conducted a population-based, case-control study in Washington State, from 1987 through 2011. Cases comprised all women with selected International Classification of Diseases, Ninth Edition, Clinical Modification codes for hospitalized VTE within 3 months post-delivery. Controls were randomly selected postpartum women who did not experience a VTE. Characteristics of women and their deliveries were abstracted from birth certificates. Using logistic regression models, we compared the risk of postpartum VTE in black, Asian, and Hispanic women with that in non-Hispanic white women, after adjustment for maternal characteristics (age, body mass index, parity, education), pregnancy complications, and delivery methods.

RESULTS

Our study comprised 688 cases and 10 246 controls. Among controls, the mean age and body mass index were 27.5 years and 26.3 kg m(-2) , respectively. Compared with white women, black and Asian women had a greater and lower risk of postpartum VTE (adjusted odds ratio [OR] 1.50, 95% confidence interval [CI] 1.10-2.04 and OR 0.67, 95%CI 0.48-0.94, respectively). A lower risk was present in Hispanic women (adjusted OR 0.80, 95% CI 0.61-1.06) but was not statistically significant. In subgroup analyses, we observed an increased risk for black compared with white women among women who delivered via cesarean section (OR 2.03, 95% CI 1.34-3.07) but not among vaginal deliveries (OR 1.03, 95% CI 0.61-1.74).

CONCLUSIONS

Maternal race/ethnicity is associated with the risk of postpartum VTE, independently of other risk factors, and should be considered when assessing the use of thromboprophylaxis after delivery.

[Age-adjusted D-dimers and pulmonary embolism]

Plasma D-dimer measurement is the first diagnostic test performed in patients with a non-high or an unlikely clinical probability of pulmonary embolism (PE) but its clinical usefulness is limited in elderly patients due to a low specificity in this subgroup. PE can be excluded based on D-dimers and clinical probability only in about 5% of patients over 80 years when using the conventional cut-off. Age-adjusted D-dimer cut-off (adjusted cut-off value = age x 10 in patients over 50) increases the specificity of the test without significantly reducing its sensitivity. Using the age-adjusted D-dimer cut-off markedly reduces the need for further diagnostic studies such as computed tomography pulmonary angiography (CTPA). The age-adjusted cut-off has been widely validated in retrospective cohorts, and more recently in a prospective management study.

Risk of falls and bleeding in elderly patients with acute venous thromboembolism

OBJECTIVE

Whether or not a high risk of falls increases the risk of bleeding in patients receiving anticoagulants remains a matter of debate.

METHODS

We conducted a prospective cohort study involving 991 patients ≥ 65 years of age who received anticoagulants for acute venous thromboembolism (VTE) at nine Swiss hospitals between September 2009 and September 2012. The study outcomes were as follows: the time to a first major episode of bleeding; and clinically relevant nonmajor bleeding. We determined the associations between the risk of falls and the time to a first episode of bleeding using competing risk regression, accounting for death as a competing event. We adjusted for known bleeding risk factors and anticoagulation as a time-varying covariate.

RESULTS

Four hundred fifty-eight of 991 patients (46%) were at high risk of falls. The mean duration of follow-up was 16.7 months. Patients at high risk of falls had a higher incidence of major bleeding (9.6 vs. 6.6 events/100 patient-years; P = 0.05) and a significantly higher incidence of clinically relevant nonmajor bleeding (16.7 vs. 8.3 events/100 patient-years; P < 0.001) than patients at low risk of falls. After adjustment, a high risk of falls was associated with clinically relevant nonmajor bleeding [subhazard ratio (SHR) = 1.74, 95% confidence interval (CI) = 1.23-2.46], but not with major bleeding (SHR = 1.24, 95% CI = 0.83-1.86).

CONCLUSION

In elderly patients who receive anticoagulants because of VTE, a high risk of falls is significantly associated with clinically relevant nonmajor bleeding, but not with major bleeding. Whether or not a high risk of falls is a reason against providing anticoagulation beyond 3 months should be based on patient preferences and the risk of VTE recurrence.

Prospective, multicenter validation of prediction scores for major bleeding in elderly patients with venous thromboembolism

BACKGROUND

The Outpatient Bleeding Risk Index (OBRI) and the Kuijer, RIETE and Kearon scores are clinical prognostic scores for bleeding in patients receiving oral anticoagulants for venous thromboembolism (VTE). We prospectively compared the performance of these scores in elderly patients with VTE.

METHODS

In a prospective multicenter Swiss cohort study, we studied 663 patients aged ≥ 65 years with acute VTE. The outcome was a first major bleeding at 90 days. We classified patients into three categories of bleeding risk (low, intermediate and high) according to each score and dichotomized patients as high vs. low or intermediate risk. We calculated the area under the receiver-operating characteristic (ROC) curve, positive predictive values and likelihood ratios for each score.

RESULTS

Overall, 28 out of 663 patients (4.2%, 95% confidence interval [CI] 2.8-6.0%) had a first major bleeding within 90 days. According to different scores, the rate of major bleeding varied from 1.9% to 2.1% in low-risk, from 4.2% to 5.0% in intermediate-risk and from 3.1% to 6.6% in high-risk patients. The discriminative power of the scores was poor to moderate, with areas under the ROC curve ranging from 0.49 to 0.60 (P = 0.21). The positive predictive values and positive likelihood ratios were low and varied from 3.1% to 6.6% and from 0.72 to 1.59, respectively.

CONCLUSION

In elderly patients with VTE, existing bleeding risk scores do not have sufficient accuracy and power to discriminate between patients with VTE who are at a high risk of short-term major bleeding and those who are not.

The history and historical treatments of deep vein thrombosis

Deep vein thrombosis (DVT) is a common disease. However, unlike that of varicose veins, which have been depicted since antiquity in art and literature, its description was more recent in the history of medicine. The first well-documented case of DVT was reported during the Middle Ages: in 1271, Raoul developed a unilateral edema in the ankle, which then extended to the leg. The number of reported DVT cases steadily increased thereafter, particularly in pregnant and postpartum women. During the first half of the 20th century, well before the discovery of anticoagulants, many therapeutic approaches were used, and arose from the pathologic hypotheses that prevailed at their time. Despite the development of anticoagulants, and the fact that they were thought to dramatically decrease DVT mortality, numerous complementary treatments have also been developed during the last 50 years: they include vena cava clips and surgical thrombectomy, and are intended to decrease mortality or to prevent late complications. Most of these treatments have now been abandoned, or even forgotten. In this review, we recall also the discovery and the use of vitamin K antagonists and heparin, which have constituted the mainstay of treatment for decades. We also bring some perspective to historical aspects of this disease and its treatment, notably regarding elastic compression and early mobilization, but also abandoned and complementary treatments. In these times of change regarding DVT treatment, mainly marked by the arrival of new oral anticoagulants, efforts of physicians through the ages to treat this common disease provide a beautiful example of the history of knowledge.

[Usefulness of preemptive anticoagulation in patients with suspected pulmonary embolism]

The usefulness of anticoagulation in patients with suspected non-massive pulmonary embolism (PE) is uncertain. We recently published a decision analysis model suggesting a benefit for preemptive anticoagulation in patients with an intermediate or high probability of PE, even with short diagnostic delays (0-3 h). In case of a low probability of PE, the decision to treat or not could partly rely on the expected diagnostic delay. Once the diagnosis is confirmed, achieving rapidly therapeutic anticoagulation levels decreases future thrombotic complications.

Prospective comparison of clinical prognostic scores in elder patients with a pulmonary embolism

BACKGROUND

The Geneva Prognostic Score (GPS), the Pulmonary Embolism Severity Index (PESI) and its simplified version (sPESI) are well-known clinical prognostic scores for a pulmonary embolism (PE).

OBJECTIVES

To compare the prognostic performance of these scores in elderly patients with a PE.

PATIENTS AND METHODS

In a multicenter Swiss cohort of elderly patients with venous thromboembolism, we prospectively studied 449 patients aged ≥ 65 years with a symptomatic PE. The outcome was 30-day overall mortality. We dichotomized patients as low vs. higher risk in all three scores using the following thresholds: GPS scores ≤ 2 vs. > 2, PESI risk classes I-II vs. III-V and sPESI scores 0 vs. ≥ 1. We compared 30-day mortality in low- vs. higher-risk patients and the areas under the receiver-operating characteristic curve (ROC).

RESULTS

Overall, 3.8% of patients (17/449) died within 30 days. The GPS classified a greater proportion of patients as low risk (92% [413/449]) than the PESI (36.3% [163/449]) and the sPESI (39.6% [178/449]) (P < 0.001 for each comparison). Low-risk patients based on the sPESI had a mortality of 0% (95% confidence interval [CI] 0-2.1%) compared with 0.6% (95% CI 0-3.4%) for low-risk patients based on the PESI and 3.4% (95% CI 1.9-5.6%) for low-risk patients based on the GPS. The areas under the ROC curves were 0.77 (95% CI 0.72-0.81), 0.76 (95% CI 0.72-0.80) and 0.71 (95% CI 0.66-0.75), respectively (P = 0.47).

CONCLUSIONS

In this cohort of elderly patients with PE, the GPS identified a higher proportion of patients as low risk but the PESI and sPESI were more accurate in predicting mortality.

Diagnosis of and treatment for symptomatic carotid stenosis: an updated review

Carotid stenoses of ≥50% account for about 15-20% of strokes. Their degree may be moderate (50-69%) or severe (70-99%). Current diagnostic methods include ultrasound, MR- or CT-angiography. Stenosis severity, irregular plaque surface, and presence of microembolic signals detected by transcranial Doppler predict the early recurrence risk, which may be as high as 20%. Initial therapy comprises antiplatelets and statins. Benefit of revascularization is greater in men, in older patients, and in severe stenosis; patients with moderate stenoses may also profit particularly if the plaque has an irregular aspect. An intervention should be performed within <2 weeks. In large randomized studies comparing endarterectomy and stenting, endovascular therapy was associated with a higher risk of periprocedural stroke, yet in some studies, with a lower risk of myocardial infarction and of cranial neuropathy. These trials support endarterectomy as the first choice treatment. Risk factors for each of the two therapies have been indentified: coronary artery disease, neck radiation, contralateral laryngeal nerve palsy for endarterectomy, and, elderly patients (>70 years), arch vessel tortuosity and plaques with low echogenicity on ultrasound for carotid stenting. Lastly, in direct comparisons, a contralateral occlusion increases the risk of periprocedural complications in both types of treatment.