Developing a Diagnostic Multivariable Prediction Model for Urinary Tract Cancer in Patients Referred with Haematuria: Results from the IDENTIFY Collaborative Study

BACKGROUND

Patient factors associated with urinary tract cancer can be used to risk stratify patients referred with haematuria, prioritising those with a higher risk of cancer for prompt investigation.

OBJECTIVE

To develop a prediction model for urinary tract cancer in patients referred with haematuria.

DESIGN, SETTING, AND PARTICIPANTS

A prospective observational study was conducted in 10 282 patients from 110 hospitals across 26 countries, aged ≥16 yr and referred to secondary care with haematuria. Patients with a known or previous urological malignancy were excluded.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcomes were the presence or absence of urinary tract cancer (bladder cancer, upper tract urothelial cancer [UTUC], and renal cancer). Mixed-effect multivariable logistic regression was performed with site and country as random effects and clinically important patient-level candidate predictors, chosen a priori, as fixed effects. Predictors were selected primarily using clinical reasoning, in addition to backward stepwise selection. Calibration and discrimination were calculated, and bootstrap validation was performed to calculate optimism.

RESULTS AND LIMITATIONS

The unadjusted prevalence was 17.2% (n = 1763) for bladder cancer, 1.20% (n = 123) for UTUC, and 1.00% (n = 103) for renal cancer. The final model included predictors of increased risk (visible haematuria, age, smoking history, male sex, and family history) and reduced risk (previous haematuria investigations, urinary tract infection, dysuria/suprapubic pain, anticoagulation, catheter use, and previous pelvic radiotherapy). The area under the receiver operating characteristic curve of the final model was 0.86 (95% confidence interval 0.85-0.87). The model is limited to patients without previous urological malignancy.

CONCLUSIONS

This cancer prediction model is the first to consider established and novel urinary tract cancer diagnostic markers. It can be used in secondary care for risk stratifying patients and aid the clinician's decision-making process in prioritising patients for investigation.

PATIENT SUMMARY

We have developed a tool that uses a person's characteristics to determine the risk of cancer if that person develops blood in the urine (haematuria). This can be used to help prioritise patients for further investigation.

Optimizing prognosis in atrial fibrillation: A call to action in Portugal

Atrial fibrillation (AF), the most common arrhythmia in the adult population worldwide, represents a significant burden in terms of cardiovascular mortality and morbidity and has repercussions on health economics. Oral anticoagulation (OAC) is key to stroke prevention in AF and, in recent years, results from landmark clinical trials of non-vitamin K oral anticoagulants (NOAC) have triggered a paradigm shift in thrombocardiology. Despite these advances, there is still a significant residual vascular risk associated with silent AF, bleeding, premature sudden death and heart failure. The authors review AF epidemiologic data, the importance of new tools for early AF detection, the current role of catheter ablation for rhythm control in AF, the state-of-the-art in periprocedural OAC, the optimal management of major bleeding, the causes of residual premature death and future strategies for improvements in AF prognosis.

(Absence of) Association Between Non-Vitamin K Antagonist Oral Anticoagulant Therapy and Urinary Tract Infection in Patients With Atrial Fibrillation

ABSTRACT

The aim of the present study is to identify a potential association of urinary tract infections (UTI) in a large population of patients receiving oral anticoagulation therapy treated in general practices in Germany. This study contains patients diagnosed with atrial fibrillation who received at least one prescription of either non-vitamin K antagonist oral anticoagulation (NOAC) or vitamin K antagonists (VKA) within January 2015 and December 2018. The incidence of UTI was examined cumulatively on the basis of Kaplan-Meier methods and was complemented by incidence rates measured in cases per 1000 patient years. Sex-stratified Cox regressions were conducted to examine possible associations in specific sex groups. The study comprised 26,934 patients receiving NOAC therapy and 8121 patients treated with VKA agents. Within a period of 5 years, slightly more NOAC than VKA users were diagnosed with UTI (20.3% vs. 19.3%), whereas the incidence rate was slightly higher in patients receiving NOAC therapy than in those under VKA treatment (50.8 cases vs. 50.5 cases in 1000 patient years). There was no significant association between direct oral anticoagulants versus vitamin K antagonists and infections of the urinary tract. Our study did not identify any significant association between therapy with direct oral anticoagulants versus vitamin K anticoagulants and UTI in patients diagnosed with atrial fibrillation in general practices in Germany. Because current findings regarding the risk of UTI in patients receiving oral anticoagulation therapy remain limited and contradictory, further investigations including a broad patient population are necessary to determine patients at risk for UTI and reconcile conflicting evidence.

CATCH-22: a manual bladder washout protocol to improve care for clot retention

PURPOSE

To review current practices in manual bladder washouts (MBW) for haematuria with clot retention, comparing those conducted by a urology unit to other inpatient services. Secondly, to describe a standardised protocol for MBWs.

METHODS

Prospective data were collected for patients treated for clot retention, from initial management by referral units through to implementation of a standardised MBW by the urology service. Outcomes measured included re-catheterisation, MBW volumes, clot evacuated and time to discharge or subsequent intervention.

RESULTS

Initial catheters inserted by referral teams were sized 16 Fr-20 Fr, all except one requiring upsizing. Mean washout volumes of 145 ml (SD 125) and 5392 ml (SD 847) were used by referring units and the urology service, respectively. Mean volume of clot evacuated by the standardised MBW was 617 ml (SD 313). Continuous bladder irrigation (CBI) was commenced in 16 patients (66%) prior to referral to urology. Median time to discharge was 48 h.

CONCLUSION

Initial catheter insertion is of inadequate size, as is the volume of washout performed. Referring services fail to clear adequate amounts of clot with washouts posing potential risks to patients. The standard management of clot retention should involve the use of at least a 22 F catheter, implement best practice infection control and adopt the last Clot + 1L rule with catheter manipulation. The key points of our recommended MBW are summarised with the acronym CATCH-22. This protocol can guide initial management of clot retention and be used as an educational tool.

[Differential diagnosis of hematuria]

Hematuria is the main symptom of many urological and nephrological diseases. In the differential diagnostics a distinction is made between painful and pain-free and between macrohematuria which is visible to the naked eye and microhematuria which is not visible. The reasons for hematuria are basically renal (glomerular) and non-renal (non-glomerular) causes. In order not to overlook early symptoms of malignant and relevant benign diseases and also to avoid excessive diagnostic tests, a differentiated approach is necessary.

Anticoagulant-related hospital admissions: serious adverse reactions identified through hospital databases

PURPOSE

A growing number of patients today receive anticoagulants. These drugs can cause serious adverse reactions leading to patients' hospitalization. The present study aimed to assess the number of hospital admissions as a result of anticoagulant adverse reactions in Alsace, a French region of 1.8 million inhabitants, and to estimate the economic burden associated with their management.

METHODS

A retrospective analysis was performed using data extracted from the regional and anonymous hospital Programme de Médicalisation des Systèmes d'Information (PMSI) database to assess the number of hospital admissions and the associated costs. Stays from public and private hospitals were extracted from the database using two International Classification of Diseases, 10th revision, codes referring to anticoagulant drugs: 'T45.5-Poisoning by anticoagulants' and 'Y44.2-Anticoagulants' adverse effect in therapeutic use'. Costs were calculated from official French tariffs.

RESULTS

Within a 2-year period from 1 Januray 2010 to 31 December 2011, 462 anticoagulant-related hospital admissions, predominantly in elderly patients, were identified in Alsace. These stays, as a result of anticoagulant adverse reactions, represented a cost of 2 050 127.86 euros (including hospitalization and expensive drugs).

CONCLUSION

Regional PMSI database constitutes an effective tool to explore anticoagulant-related hospital admissions. Based on our study, one can state that the cost of anticoagulation therapies lies not only in the price of the drugs but also in the cost of adverse reaction management. Policy makers should be aware of this reality and should focus on better medication supervision in order to improve patient safety and reduce expenses.