Comparative clinical prognosis of massive and non-massive pulmonary embolism: A registry-based cohort study

AIMS

Little is known about the prognosis of patients with massive pulmonary embolism (PE) and its risk of recurrent venous thromboembolism (VTE) compared with non-massive PE, which may inform clinical decisions. Our aim was to compare the risk of recurrent VTE, bleeding, and mortality after massive and non-massive PE during anticoagulation and after its discontinuation.

METHODS AND RESULTS

We included all participants in the RIETE registry who suffered a symptomatic, objectively confirmed segmental or more central PE. Massive PE was defined by a systolic hypotension at clinical presentation (<90 mm Hg). We compared the risks of recurrent VTE, major bleeding, and mortality using time-to-event multivariable competing risk modeling. There were 3.5% of massive PE among 38 996 patients with PE. During the anticoagulation period, massive PE was associated with a greater risk of major bleeding (subhazard ratio [sHR] 1.72, 95% confidence interval [CI] 1.28-2.32), but not of recurrent VTE (sHR 1.15, 95% CI 0.75-1.74) than non-massive PE. An increased risk of mortality was only observed in the first month after PE. After discontinuation of anticoagulation, among 11 579 patients, massive PE and non-massive PE had similar risks of mortality, bleeding, and recurrent VTE (sHR 0.85, 95% CI 0.51-1.40), but with different case fatality of recurrent PE (11.1% versus 2.4%, P = .03) and possibly different risk of recurrent fatal PE (sHR 3.65, 95% CI 0.82-16.24).

CONCLUSION

In this large prospective registry, the baseline hemodynamic status of the incident PE did not influence the risk of recurrent VTE, during and after the anticoagulation periods, but was possibly associated with recurrent PE of greater severity.

D-dimer levels and risk of recurrence following provoked venous thromboembolism: findings from the RIETE registry

BACKGROUND

Patients with venous thromboembolism (VTE) secondary to transient risk factors may develop VTE recurrences after discontinuing anticoagulation. Identifying at-risk patients could help to guide the duration of therapy.

METHODS

We used the RIETE database to assess the prognostic value of d-dimer testing after discontinuing anticoagulation to identify patients at increased risk for recurrences. Transient risk factors were classified as major (postoperative) or minor (pregnancy, oestrogen use, immobilization or recent travel).

RESULTS

In December 2018, 1655 VTE patients with transient risk factors (major 460, minor 1195) underwent d-dimer measurements after discontinuing anticoagulation. Amongst patients with major risk factors, the recurrence rate was 5.74 (95% CI: 3.19-9.57) events per 100 patient-years in those with raised d-dimer levels and 2.68 (95% CI: 1.45-4.56) in those with normal levels. Amongst patients with minor risk factors, the rates were 7.79 (95% CI: 5.71-10.4) and 3.34 (95% CI: 2.39-4.53), respectively. Patients with major risk factors and raised d-dimer levels (n = 171) had a nonsignificantly higher rate of recurrences (hazard ratio [HR]: 2.14; 95% CI: 0.96-4.79) than those with normal levels. Patients with minor risk factors and raised d-dimer levels (n = 382) had a higher rate of recurrences (HR: 2.34; 95% CI: 1.51-3.63) than those with normal levels. On multivariate analysis, raised d-dimers (HR: 1.74; 95% CI: 1.09-2.77) were associated with an increased risk for recurrences in patients with minor risk factors, not in those with major risk factors.

CONCLUSIONS

Patients with raised d-dimer levels after discontinuing anticoagulant therapy for VTE provoked by a minor transient risk factor were at an increased risk for recurrences.

Trends and prediction of antimicrobial susceptibility in urinary bacteria isolated in European emergency departments: the EuroUTI 2010-2016 Study

Objectives

To assess recent trends in susceptibility to antibiotics among urinary isolates isolated in European emergency departments (EDs) and to identify isolates with a high (90% or more) predicted probability of susceptibility to fluoroquinolones or third-generation cephalosporins (3GCs).

Methods

In this cross-sectional study, we included urine cultures obtained from adult patients between 2010 and 2016 in 24 European EDs. Temporal trends were assessed using time-series analysis and multivariate logistic models. Multivariate logistic models were also used to predict susceptibility to fluoroquinolones or 3GCs from patient age and sex, year, month and ED.

Results

We included 88242 isolates. Time-series analysis found a significant increase in susceptibility to fluoroquinolones and no significant trend for susceptibility to 3GCs. Adjusting for patient age and sex, ED and organism, multivariate models showed that susceptibility to 3GCs decreased from 2014 to 2016, while susceptibility to fluoroquinolones increased in 2015 and 2016. Among isolates from 2016, multivariate models predicted high probability of susceptibility to fluoroquinolones in 11% of isolates (positive predictive value 91%) and a high probability of susceptibility to 3GCs in 35% of isolates (positive predictive value 94%).

Conclusions

Susceptibility of ED urinary isolates to fluoroquinolones increased from 2014, while susceptibility to 3GCs decreased from 2015. Predictive models identified isolates with a high probability of susceptibility to fluoroquinolones or 3GCs. The ability of such models to guide the empirical treatment of pyelonephritis in the ED remains to be determined.

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.

Outcome of Patients with Venous Thromboembolism and Factor V Leiden or Prothrombin 20210 Carrier Mutations During the Course of Anticoagulation

BACKGROUND

Individuals with factor V Leiden or prothrombin G20210A mutations are at a higher risk to develop venous thromboembolism. However, the influence of these polymorphisms on patient outcome during anticoagulant therapy has not been consistently explored.

METHODS

We used the Registro Informatizado de Enfermedad TromboEmbólica database to compare rates of venous thromboembolism recurrence and bleeding events occurring during the anticoagulation course in factor V Leiden carriers, prothrombin mutation carriers, and noncarriers.

RESULTS

Between March 2001 and December 2015, 10,139 patients underwent thrombophilia testing. Of these, 1384 were factor V Leiden carriers, 1115 were prothrombin mutation carriers, and 7640 were noncarriers. During the anticoagulation course, 160 patients developed recurrent deep vein thrombosis and 94 patients developed pulmonary embolism (16 died); 154 patients had major bleeding (10 died), and 291 patients had nonmajor bleeding. On multivariable analysis, factor V Leiden carriers had a similar rate of venous thromboembolism recurrence (adjusted hazard ratio [HR], 1.16; 95% confidence interval [CI], 0.82-1.64), half the rate of major bleeding (adjusted HR, 0.50; 95% CI, 0.25-0.99) and a nonsignificantly lower rate of nonmajor bleeding (adjusted HR, 0.66; 95% CI, 0.43-1.01) than noncarriers. Prothrombin mutation carriers and noncarriers had a comparable rate of venous thromboembolism recurrence (adjusted HR, 1.00; 95% CI, 0.68-1.48), major bleeding (adjusted HR, 0.75; 95% CI, 0.42-1.34), and nonmajor bleeding events (adjusted HR, 1.10; 95% CI, 0.77-1.57).

CONCLUSIONS

During the anticoagulation course, factor V Leiden carriers had a similar risk for venous thromboembolism recurrence and half the risk for major bleeding compared with noncarriers. This finding may contribute to decision-making regarding anticoagulation duration in selected factor V Leiden carriers with venous thromboembolism.

Assessment of urinary dipstick in patients admitted to an ED for blunt abdominal trauma

INTRODUCTION

Clinicians still face significant challenge in predicting intra-abdominal injuries in patients admitted to an emergency department for blunt abdominal trauma. This study was thus designed to investigate the value of dipstick urinalysis in patients with blunt abdominal trauma.

METHODS

We performed a retrospective, multicenter, cohort study involving patients admitted to the emergency department for abdominal traumas, examined by means of urinary dipstick and abdominal CT scan. The primary endpoint was the correlation between microscopic hematuria detected via dipstick urinalysis (defined by the presence of blood on the dipstick urinalysis but without gross hematuria) and abdominal injury, as evidenced on CT scan.

RESULTS

Of the 100 included patients, 56 experienced microscopic hematuria, 17 gross hematuria, and 44 no hematuria. Patients with abdominal injury were more likely to present with hypovolemic shock (odds ratio [OR]: 8.4; 95% confidence interval [CI]: 2.7-26), abdominal wall hematoma (OR: 3.1; 95% CI: 1.2-7.9), abdominal defense (OR: 5.2; 95% CI: 1.8-14.5), or anemia (OR: 3.6; 95% CI: 1.2-10.3). Moreover, dipstick urinalysis was less likely to predict injury, with just 72.2% sensitivity (95% CI: 54.8-85.8), 53.1% specificity (95% CI: 40.2-65.7), and positive and negative predictive values of 46.4% (95% CI: 33.0-60.3) and 77.3% (95% CI: 62.2-88.5), respectively.

CONCLUSION

Dipstick urinalysis was neither adequately specific nor sensitive for predicting abdominal injury and should thus not be used as a key assessment component in patients suffering from blunt abdominal trauma, with physical exam and vital sign assessment the preferred choice.

Living-related-donor kidney transplantation outcome in recipients with primary focal-segmental glomerulosclerosis

We studied the outcome of renal transplantation in 30 patients with primary focal-segmental glomerulosclerosis (FSGS) and in 30 controls in whom renal failure was secondary to nonglomerular renal diseases. All patients received living-related-donor kidneys, and the majority had one-haplotype HLA matching. Within the follow-up period, the mean serum creatinine values were significantly higher in FSGS recipients as compared with the control group (p = 0.02). However, the frequency of acute rejection episodes and the mean blood pressure values were not significantly different between the two groups. There was a tendency of a higher incidence of proteinuria among FSGS recipients in comparison with the controls. Moreover, nephrotic-range proteinuria occurred only in 3 recipients of the FSGS group. Recurrence of FSGS was morphologically documented in 2 recipients 7 and 18 months, respectively, after transplantation. It is concluded that FSGS as the primary disease has a negligible impact on the living-related-donor kidney transplantation in the Egyptian population. Therefore, this disease should not discourage transplantation for this group of patients.

Effect of colchicine on chronic ciclosporin nephrotoxicity in Sprague-Dawley rats

Thirty male Sprague-Dawley rats were given ciclosporin (Cs) orally, 15 mg/kg daily for 80 days. Fifteen served as positive controls, while the other 15 were given daily colchicine at a dose of 30 microg/kg in addition to Cs. Additional 15 rats were given olive oil only and served as negative controls. The animals were subjected every other week to laboratory assessment of serum creatinine, sodium, potassium, and Cs whole-blood trough levels; also urine samples were examined for creatinine, sodium, potassium, and protein concentrations. At the end point, the animals were sacrificed, and kidney tissue was examined for histopathological changes. Comparing negative control versus Cs-treated and Cs-plus-colchicine-treated rats, there were no significant differences in serum creatinine, creatinine clearance, and serum and urine values of sodium and potassium as well as urinary protein/creatinine ratios. Yet histopathological examination of kidney tissues showed focal tubular atrophy and interstitial fibrosis in inner medulla and inner stripe of the outer medulla in all Cs-treated animals and in only 1 of the colchicine-treated group, but in none of the negative controls. Histological changes in other kidney zones in different animal groups were minor and not different. From this study, we may conclude that colchicine is of protective value against chronic Cs nephrotoxicity in Sprague-Dawley rats.

Schistosomal-specific nephropathy in Syrian golden hamsters: treatment by induction of antigen excess

One hundred and twenty Syrian golden hamsters were infected with Schistosoma mansoni cercariae and 20 served as negative controls (group I). Of the S. mansoni-infected hamsters, 20 served as positive controls (group II) and 100 hamsters were treated for 12 weeks post-infection by loading with S. mansoni adult worm antigen. Animals were divided into groups according to the dose of adult worm antigen injected: group III (5-fold increase in circulating antigen concentration), group IV (10-fold increase), group V (20-fold increase), group VI (40-fold increase), and group VII (80-fold increase). Each of the groups was subdivided into four groups (sacrificed at 1, 2, 4 or 7 days after initiation of antigen loading or the corresponding time points in the case of the control groups). At sacrifice, blood and urine were obtained for laboratory assessment (serum creatinine, protein, albumin, cholesterol and urinary proteins). Kidney, liver and spleen tissue specimens were obtained for light, immunofluorescent and electron microscopic examinations. At sacrifice, significant proteinuria, hypoalbuminaemia and hypercholesterolaemia were observed in S. mansoni-infected hamsters when compared with negative control animals. Histopathologic assessment showed changes compatible with those previously reported, mainly immune complex glomerular deposits, mesangial proliferation and renal amyloid deposits. Significant laboratory improvement was observed in animals treated with antigen loading, especially those treated with 80-fold antigen excess and sacrificed at 7 days postinitiation of treatment. Histopathologic evaluation showed significantly less immune complex glomerular deposits, less mesangial hyperplasia, and less amyloid deposits in hamsters treated with antigen loading. It is concluded that induction of antigen excess by antigen loading induces biochemical and histopathologic regression of schistosomal-specific nephropathy in S. mansoni-infected Syrian golden hamsters.

Study of morphologic risk factors in graft biopsies from patients with living related donor kidney transplants

In this work, 205 graft biopsies obtained from 161 living related donor kidney transplant recipients were blindly reevaluated by our nephropathologist, and individual lesions were evaluated semiquantitatively. Glomerular lesions included capillary thrombosis, cellular infiltrate, mesangial matrix thickening, glomerulonephritis and the presence of glomerular crescents. Tubulointerstitial lesions included tubular necrosis, tubulitis, tubular atrophy, interstitial hemorrhage, interstitial inflammatory cellular infiltrate and infarction. Vascular lesions included endovasculitis, arteriolar wall fibrinoid necrosis and intimal fibrosis. Graft outcome was assessed by looking for the changes in serum creatinine at 3 months postbiopsy and regularly every 3 months until 36 months thereafter. Other variables were considered including patient age, timing of biopsy posttransplantation, and type of immune suppression. Statistical analyses were performed to study the impact of each individual lesion on graft outcome as judged by changes in serum creatinine. Furthermore, models were constructed for short- and long-term graft outcome. Arteriolar wall fibrinoid necrosis, tubular necrosis, glomerular capillary thrombosis and increased mesangial matrix thickness were the most serious lesions affecting graft outcome.

Coadministration of ketoconazole to cyclosporin-treated kidney transplant recipients: a prospective randomized study

In this work, 100 living related donor kidney transplant recipients under cyclosporin (CsA) therapy were randomly distributed to two groups. Group 1 were administered ketoconazole, with group 2 serving as the control. Ketoconazole was given orally, 100 mg/day, while the dose of CsA was adjusted for a CsA whole blood trough level of 100-150 ng/ml. Patients and controls were assessed regularly in an outpatient clinic for 12 months and compared statistically for CsA dose, graft and liver functions, cholesterol, blood sugar, CsA nephrotoxicity, acute rejection episodes, chronic rejection and fungal skin infections. Statistical analysis showed a significant reduction in the CsA dose in the ketoconazole-treated group (73-76%), along with significantly lower alanine aminotransferase, aspartate aminotransferase, bilirubin, and serum creatinine values. CsA chronic nephrotoxicity and chronic rejections were also significantly lower in the ketoconazole-treated group, as was fungal skin infection (6.6 vs 63.2%). From this study, we conclude that addition of a low dose of ketoconazole to CsA-treated kidney transplant recipients not only saves costs, but may also have a favorable effect on graft function, chronic CsA nephrotoxicity, chronic rejection and fungal skin infection.

Effect of colchicine on schistosoma-induced renal amyloidosis in Syrian golden hamsters

Seventy Syrian golden hamsters were infected with Schistosoma haematobium, and 10 uninfected hamsters served as negative controls. Of the schistosome-infected hamsters, 10 served as positive controls (infected but untreated) and the rest (60 hamsters) received treatment. In 30 hamsters treatment was given 9 weeks after infection (before the appearance of renal amyloidosis) and in the other 30 it was given after the appearance of amyloid deposits, 15 weeks after infection. Each treatment group was subdivided into 3 groups (10 hamsters each) in which treatment was either anti-schistosomal alone, combined anti-schistosomal and colchicine, or colchicine alone. Eighteen weeks after infection half of the animals in each group were sacrificed, while the rest were sacrificed 24 weeks after infection. Kidney specimens were evaluated semiquantitatively for renal amyloid deposits. Significant reductions in renal amyloid deposits and proteinuria were observed when combined treatment was given. This was nearly complete with early treatment and only partial when treatment was given late. When colchicine was given alone, a partial but significant reduction in proteinuria with no recognizable effect on renal amyloid deposits was observed. We conclude that colchicine is effective for the prevention and cure of schistosome-related renal amyloidosis in golden hamsters.

Study of live donor kidney transplantation outcome in recipients with renal amyloidosis

We studied the results of renal transplantation in 16 patients with renal amyloidosis and in 46 controls with primary glomerulonephritis. Amyloidosis was primary in five and secondary to familial Mediterranean fever (FMF) in 11. All patients received live related donor kidneys and the majority had one-haplotype HLA match. One- and 5-year graft and patient survival rates were comparable in both groups. Moreover, the frequency of acute rejection episodes and the mean serum creatinine values were not significantly different between members of the two groups. Significant gastrointestinal symptoms in the form of nausea, vomiting, abdominal pains, and diarrhoea occurred in seven of the patients with amyloidosis (43.7%) and in only one of the controls (2%) (P = 0.001). All seven recipients with amyloidosis who developed the gastrointestinal manifestations were receiving cyclosporin and six had FMF. Maintenance colchicine treatment prevented recurrence of FMF symptoms. In one patient discontinuation of colchicine was followed by recurrence of FMF symptoms. Recurrence of renal amyloidosis was not observed in five patients subjected to Trucut graft biopsies 1, 2, 3, 18 and 72 months post-transplantation. It is concluded that live-related donor kidney transplantation is a safe procedure in patients with amyloidosis and follows a course similar to glomerulonephritis patients.

Schistosoma mansoni nephropathy in Syrian golden hamsters: effect of dose and duration of infection

In this work, 180 golden hamsters were infected with Schistosoma mansoni and 30 hamsters matched for age and sex served as controls. According to the number of injected cercariae, infected hamsters were divided into six main groups (20, 50, 100, 150, 200 and 250 cercariae). Each group was divided into five subgroups, according to the duration of infection after which animals were sacrificed (4, 6, 8, 12 and 24 weeks). Control and infected hamsters were subjected to laboratory evaluations (serum creatinine, blood urea nitrogen, cholesterol, albumin, total protein and urine protein concentration) and histopathologic examinations of kidney and liver tissues. A significant proteinuria, hypoalbuminemia and hypercholesterolemia was observed in schistosome infected (50 cercariae or more) but not in the controls and the group infected with 20 cercariae. There was significant correlation between these changes and duration of infection and the number of adult worm recovered from the mesenteric circulation at the end of the experiments. Histopathologic evaluation showed appearance of the circulating schistosome antigens, circulating anodic antigen (CAA) and circulating cathodic antigen (CCA), and of IgG glomerular deposits by the 6th week following infection; mesangial hypercellularity appeared early after infection (6-8 weeks), renal amyloid deposition appeared later (8-12 weeks). Egg antigens were not detected in the renal glomeruli. There was a significant correlation between the pathologic changes and duration of infection and the number of recovered adult worms from the mesenteric circulation. No histopathologic lesions were detected in controls and the group injected with 20 cercariae. A significant correlation was found between hepatic periportal fibrosis, amyloidosis and immune complex, deposition in the renal glomeruli. Hamsters did not tolerate infection with 150 cercariae or more for more than 12 weeks, and 20 cercariae caused no detectable glomerular disease. From this study, we concluded that S. mansoni infection causes nephropathy in the Syrian golden hamster. The disease became biochemically and histopathologically manifest by the 6th week following infection. Both immune complex deposition and renal amyloidosis stand as major pathogenic mechanisms. CAA and CCA are the major responsible antigens. Hepatic disease has an impact on the kidney lesion. 50 cercariae are the best dose to produce disease without early death of the animal. There is a significant correlation between the kidney disease and the duration and the load of S. mansoni infection.

Nephropathy in asymptomatic patients with active Schistosoma mansoni infection

In this study 240 patients with active Schistosoma mansoni infection with no symptoms suggestive of glomerular disease were subjected to investigation. All were evaluated clinically and their urine was examined for proteinuria. Out of the 240 patients 48 (20%) had proteinuria as detected by the dipstick test. All these patients were found to be free of any secondary cause other than schistosomiasis which could explain their proteinuria. Out of these 48 patients, 15 agreed to be subjected to kidney biopsy. When examined by light microscopy and immunofluorescent microscopy, kidney biopsies showed positive findings in 8 cases. These were mainly focal mesangial proliferation and immunofluorescent deposits which were mainly IgM and C3. We have concluded that early kidney lesions could be detected in 20% of this particular group of patients.

Anatomical basis of latissimus dorsi myocutaneous flap: clinical applications

The anatomical study was carried out using 40 preserved cadaveric specimens of latissimus dorsi myocutaneous flaps. It included dissections, angiographies and tissue clearing after arterial injection with latex. The results proved that the dominant vascular supply, the thoracodorsal a., has an almost constant pattern of intramuscular distribution. In addition, there are two sets of segmental pedicles, from the intercostal and lumbar vessels, supplying the medial third of the muscle. The accurate localization of the intramuscular distribution of the thoracodorsal a. permitted the proper design of several island flaps with competent vascularity. The designed flaps were successfully applied in 10 cases for reconstruction of breast, axilla, neck and chest wall.

Value of renal biopsy in chronic renal failure

A total of 120 patients with chronic renal failure secondary to parenchymatous kidney disease were biopsied. Percutaneous approach was tried and open technique was employed when there was contraindication to or failure of the percutaneous technique. In 72 cases the histopathologic lesions were identified, in 30 cases it was not possible to identify them and in 18 cases there was no sufficient kidney tissue. The diagnosis was very critical in at least 10 cases: there were 3 cases of primary oxalosis, one case of haemolytic uraemic syndrome, one case of necrotizing glomerulonephritis, one case of Wagner's granulomatosis, 3 cases of focal segmental glomerulosclerosis and one case of Fabry's disease. All but one of these were not diagnosed clinically. There was no patient mortality, and morbidity was significantly higher after open approach. We concluded that kidney biopsy in patients with chronic renal failure is mandatory especially if they are going to be transplanted and it is relatively safe especially when the percutaneous technique is employed.