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[Display omitted] Patients hospitalised with acute venous thromboembolism (VTE), and notably patients with pulmonary embolism, often remain in hospital for extended periods due to the perceived risk of complications. However, several studies have shown that home treatment of selected patients is feasible and safe, with a low incidence of adverse events. This may offer clear benefits for patients' quality of life, hospital planning and cost to the health service. Nonetheless, there is a need for a VTE risk-stratification tool specifically addressing prognosis in patients with cancer. This may aid in the selection of low-risk patients with cancer and VTE who are suitable for outpatient treatment. Although several prognostic scores have been proposed, we suggest using a pragmatic clinical decision-making tool such as the Hestia criteria for selecting patients for home care in everyday clinical practice. Once patients have been discharged, it is mandatory to monitor patients regularly (we suggest after 3 days, 10 days, 1 month and 3 months, or more frequently if needed) with the involvement of a multidisciplinary team, so that appropriate and timely remedial action can be taken in case of warning signs of complications. If patients are selected carefully and monitored effectively, many patients who experience acute VTE can be cared for safely at home. [ABSTRACT FROM AUTHOR]

[Display omitted] Patients with cancer are at significantly increased risk of venous thromboembolism (VTE), due both to the impact of malignant disease itself and to the impact of certain anticancer drugs on haemostasis. This is true both for first episode venous thromboembolism and recurrence. The diagnosis and management of VTE recurrence in patients with cancer poses particular challenges, and these are reviewed in the present article, based on a systematic review of the relevant scientific literature published over the last decade. Furthermore, it is uncertain whether diagnostic algorithms for venous thromboembolism, validated principally in untreated non-cancer patients, are also valid in anticoagulated cancer patients: the available data suggests that clinical decision rules and D-dimer testing perform less well in this clinical setting. In patients with cancer, computed tomography pulmonary angiography and venous ultrasound appear to be the most reliable diagnostic tools for diagnosis of pulmonary embolism and deep vein thrombosis respectively. Options for treatment of venous thromboembolism include low molecular weight heparins (at a therapeutic dose or an increased dose), fondaparinux or oral direct factor Xa inhibitors. The choice of treatment should take into account the nature (pulmonary embolism or VTE) and severity of the recurrent event, the associated bleeding risk, the current anticoagulant treatment (type, dose, adherence and possible drug-drug interactions) and cancer progression. [ABSTRACT FROM AUTHOR]

Hemorrhage occurs in 7–10% of patients treated with vitamin K antagonist (VKA), with major bleeding in 1–3%. Impact of nutritional status on the bleeding risk of patients on anticoagulants is still poorly documented. Our study aimed to analyze the link between the nutritional status of patients on VKA and the occurrence of hemorrhagic events. We also analyzed micronutrients status. A case–control, monocentric, and prospective study was conducted from August 2012 to October 2015. The case patients were those presenting with major bleeding and control patients those without any bleeding under VKA treatment. Overall, 294 patients under VKA treatment were paired according to age, gender, and index normalized ratio (INR). Out of these, 98 (33.3%) had major bleeding and 196 (66.7%) did not have any bleeding. Additionally, more than two-thirds of patients displayed undernutrition, which was more prevalent in bleeding than non-bleeding patients (OR = 1.85, CI95%: 1.07–3.21). There was a higher bleeding risk for those with severe undernutrition (OR = 2.66, CI95%: 1.58–4.46), with no difference found concerning moderate undernutrition. Bleeding patients had lower plasma-zinc concentrations than non-bleeding patients (9.4 ± 3.6 vs. 10.5 ± 3.7 μmol/L, p = 0.003); among them, there was a higher rate of patients with plasma zinc under 5 μmol/L (9% vs. 2%, p < 0.001). Patients with undernutrition on VKA exhibit a significantly higher bleeding risk, which increases three-fold in case of severe undernutrition. The evaluation of nutritional status provides additional, valuable prognosis information prior to initiating VKA therapy. NCT 01742871. [ABSTRACT FROM AUTHOR]

Methods for prognosis assessment and patient management in acute pulmonary embolism (PE) are much debated among physicians. We conducted an online survey to determine physician's attitudes and barriers towards the use of prognostic models when treating patients with acute PE. Physicians members of the French and the European scientific societies for emergency medicine or of a French thrombosis research network were reached by their respective scientific societies and invited to participate via email. The questionnaire was a mixture of close-ended with yes-no or multiple-choice options and a small number of open-ended questions. The survey included 461 respondents. The most commonly used prognostic tools were clinical judgment (36%) and prognostic models (29.5%). Prognostic models were used by 57% of respondents in more than half of all cases and prognostic indicators by 62% in addition to prognostic models. Affiliation group and type of hospital emerged as independent predictors for choosing prognostic models. Many (52%) reported lack of familiarity with the models and reported clinical judgment (60%) or hospital checklists (73%) as being as good as or better than prognostic models. The highest acceptable 30-day mortality rate limit for early discharge or outpatient management was deemed to be 1%, but few patients are discharged early or completely managed on an outpatient basis. This survey provides new information for implementing knowledge translation strategies to improve prognostic risk assessment for acute PE patients, and highlights the need for considering the use of clinical judgment and hospital checklists in future clinical research. • Assessing prognosis in acute pulmonary embolism may help inform clinical management. • Our survey shows physicians mostly rely on prognostic models and clinical judgment. However, they rarely use models and often combined them with other prognostic tools. • Lack of familiarity with the models have an impact on management decisions. Few patients are discharged early or completely managed on an outpatient basis. [ABSTRACT FROM AUTHOR]

Venous thromboembolism (VTE) is a common pathology. The clinical presentation of pulmonary embolism (PE) is sometimes poor and requires the use of stratification scores for mortality risk. The s-PESI score has excellent sensitivity and a strong negative predictive value of the 30-day mortality. The main objective of our study was to evaluate the mortality at 6 months and 1 year of pulmonary embolism based on S-PESI score calculated at the emergency department during diagnosis. We performed a retrospective, single-center study of patients admitted to our university hospital emergency department for PE. The s-PESI score was calculated at admission during PE diagnosis. Of the 379 patients included, 261 (68%) were classified s-PESI ≥ 1 and 118 (32%) s-PESI = 0. The s-PESI = 0 group compared to s-PESI ≥ 1 was younger [56.8 years ± 15.6 vs. 76.5 years ± 14.4; (P < 0.001)] and had a shorter hospital stay [8.7 vs. 13.2 days; (P = 0.0001)]. In the group s-PESI ≥ 1, 38 deaths were recorded in 12 months, representing an overall survival of 82.5% at 1 year against no death in the group s-PESI = 0. Regarding the criteria of the s-PESI score, the oxygen saturation < 90% significantly increased the mortality (P < 0.03) in univariate analysis. In addition, the NT-proBNP increase and the troponin increase were significantly associated with an increase in mortality (P < 0.05 and P < 0.009, respectively). Multivariate analysis showed that a patient with a history of cancer was nine times more likely to die (HR 9.6, 95% CI = [3.98, 23.11], P < 0.001) with overall survival at 6 months of 75% (95% CI = [0.64, 0.84;] P < 0.05). Our retrospective study has shown that the s-PESI score items most predictive for mortality appear to be the presence of cancer at diagnosis and presentation with an oxygen saturation of less than 90% at admission. The use of a composite criterion with troponin and BNP include may be of interest in long-term stratification. [ABSTRACT FROM AUTHOR]

Les patients hospitalisés pour une maladie thromboembolique veineuse aiguë (MTEV), et notamment les patients souffrant d'une embolie pulmonaire, restent souvent à l'hôpital pendant de longues périodes en raison du risque perçu de complications. Cependant, plusieurs études ont montré que le traitement à domicile de patients sélectionnés est faisable et sûr, avec une faible incidence d'événements indésirables. Cela peut présenter des avantages évidents pour la qualité de vie des patients, la planification hospitalière et le coût pour les services de santé. Néanmoins, il est nécessaire de disposer d'un outil de stratification du risque de MTEV qui prenne en compte le pronostic des patients atteints de cancer. Cet outil pourrait aider à sélectionner les patients à faible risque atteints d'un cancer et d'une MTEV qui peuvent bénéficier d'un traitement ambulatoire. Bien que plusieurs scores pronostiques aient été proposés, nous suggérons d'utiliser un outil pragmatique de prise de décision clinique tel que les critères Hestia, afin de sélectionner les patients devant recevoir des soins à domicile dans la pratique clinique quotidienne. Une fois les patients sortis de l'hôpital, il est indispensable de les surveiller régulièrement (nous suggérons après 3 jours, 10 jours, 1 mois et 3 mois, ou plus fréquemment si nécessaire) avec l'implication d'une équipe multidisciplinaire, afin que des mesures correctives appropriées puissent être prises en temps voulu, en cas de signes avant-coureurs de complications. Si les patients sont sélectionnés avec soin et suivis efficacement, de nombreux cas de MTEV aiguë peuvent être soignés en toute sécurité à domicile. Patients hospitalised with acute venous thromboembolism (VTE), and notably patients with pulmonary embolism, often remain in hospital for extended periods due to the perceived risk of complications. However, several studies have shown that home treatment of selected patients is feasible and safe, with a low incidence of adverse events. This may offer clear benefits for patients' quality of life, hospital planning and cost to the health service. Nonetheless, there is a need for a VTE risk-stratification tool specifically addressing prognosis in patients with cancer. This may aid in the selection of low-risk patients with cancer and VTE who are suitable for outpatient treatment. Although several prognostic scores have been proposed, we suggest using a pragmatic clinical decision-making tool such as the Hestia criteria for selecting patients for home care in everyday clinical practice. Once patients have been discharged, it is mandatory to monitor patients regularly (we suggest after 3 days, 10 days, 1 month and 3 months, or more frequently if needed) with the involvement of a multidisciplinary team, so that appropriate and timely remedial action can be taken in case of warning signs of complications. If patients are selected carefully and monitored effectively, many patients who experience acute VTE can be cared for safely at home. [ABSTRACT FROM AUTHOR]

The prevalence of pulmonary embolism (PE) is approximately 11–17 % in patients with an acute exacerbation of chronic obstructive pulmonary disease (AE-COPD). The optimal diagnostic strategy for PE in these patients remains undetermined. To evaluate the safety and efficacy of standard (revised Geneva and Wells PE scores combined with fixed D-dimer cut-off) and computed tomography pulmonary angiogram (CTPA)-sparing diagnostic strategies (ADJUST-PE, YEARS, PEGeD, 4PEPS) in patients with AE-COPD. Post-hoc analyses of data from the multicenter prospective PEP study were performed. The primary outcome was the diagnostic failure rate of venous thromboembolism (VTE) during the entire study period. Secondary outcomes included diagnostic failure rate of PE and deep venous thrombosis (DVT), respectively, during the entire study period and the number of CTPA needed per diagnostic strategy. 740 patients were included. The revised Geneva and Wells PE scores combined with fixed D-dimer cut-off had a diagnostic failure rate of VTE of 0.7 % (95%CI 0.3 %–1.7 %), but >70.0 % of the patients needed imaging. All CTPA-sparing diagnostic algorithms reduced the need for CTPAs (−10.1 % to −32.4 %, depending on the algorithm), at the cost of an increased VTE diagnosis failure rate of up to 2.1 % (95%CI 1.2 %–3.4 %). Revised Geneva and Wells PE scores combined with fixed D-dimer cut-off were safe, but a high number of CTPA remained needed. CTPA-sparing algorithms would reduce imaging, at the cost of an increased VTE diagnosis failure rate that exceeds the safety threshold. Further studies are needed to improve diagnostic management in this population. • Optimal PE diagnostic strategy in patients with COPD is unclear. • Post-hoc analyses from the multicenter prospective PEP study were performed. • Revised Geneva/Wells PE scores with fixed D-dimer cut-off were safe, but many CTPA were needed. • CTPA-sparing algorithms would reduce imaging with an increased VTE diagnosis failure rate. [ABSTRACT FROM AUTHOR]

Objectives Acute pulmonary embolism (PE) outcome is mainly conditioned by the right ventricular dysfunction. We investigated the pronostic role of four markers of right ventricular dysfunction on computed tomography (CT): Increasing of right and left ventricle diameter ratio on axial views (RV-LVax), on four-chamber reconstructed views (RV-LV4c), pulmonary artery (PA) enlargement, and increasing of the PA / aorta diameter ratio (PA-Ao). Patients, methods We evaluated 207 patients with acute PE confirmed by chest CT in our unit from january 2007 to december 2009 (mean age 69,8± 17 years, 49,3% women). CT measures were done by two observers blinded from clinical and outcome data. The primary endpoint was the one-year mortality. Secondary endpoint was the correlation to the Pulmonary Embolism Severity Index (PESI). Results, discussion Increasing of the RV-LVax is a nearly significant predictor of one-year death (p=0,056). It is increased in 90,9% patients with massive PE. It is significantly correlated to the PESI (p<0,001). Values of RV-LVax are correlated to the values of RV-LV4c (r=0,95), but RV-LV4c is not significantly correlated to the one-year mortality mortality (p=0,173). PA diameter is significantly correlated to the axial RV/LV ratio (r=0,36); PA enlargement above 27,5 mm (determined on ROC curve, sensibility 0,65; specificity 0,67) is a significant predictor of one-year death (p=0,002), such as PA-Ao (p=0,023) Conclusion RV-LVax has an interesting pronostic value. Lack of significance could be due to the small number of patients included. RV-LV4c seems not necessary. The correlation between RV-LVax and the PESI suggests that it is a predictor of death. PA diameter and PA-Ao should be used in the risk stratification. Our study confirms the high mortality rate in massive or moderate risk PE versus low risk PE (25,4% versus 9,9%, p<0,001). Our study reaffirms the pronostic value of CT, added to its diagnostic value. [ABSTRACT FROM AUTHOR]

Bleeding during oral anticoagulant therapy is currently codified by expert guidelines. Monitoring of coagulation during bleeding events is challenging. Our study sought to assess thrombin generation assay (TGA) in direct oral anticoagulant-treated patients without bleeding (WB), bleeding without reversal therapy (BR-), and bleeding with reversal therapy (BR+). We conducted a prospective, monocentric study from June 2015 to June 2018. For all bleeding groups, TGA was evaluated using platelet-poor plasma collected upon arrival at emergency (T0), and 30 min (T1), 6 h (T2) and 24 h (T3) after reversal therapy (if indicated) following activation by tissue factor 5 pM and phospholipids. Overall, 292 patients participated, including 91 BR+, 94 BR-, and 107 WB patients. At T0, vitamin K antagonist reversed (VKA-BR+) patients experienced a significant decrease in TGA parameters (ETP and peak) compared with VKA without bleeding (VKA-WB). Compared with healthy controls, VKA-BR+ patients reversed by four-factor prothrombin complex concentrate (4F-PCC) displayed comparable TGA 's ETP and peak at T1, T2, and T3, whereas direct anti-Xa BR+ patients reversed by 4F-PCC or activated prothrombin complex concentrate (aPCC) reached thrombin generation parameters that exceeded normal range at T2 and T3. In VKA-treated patients reversed by 4F-PCC, TGA parameters were normalized, whereas in rivaroxaban or apixaban-treated patients reversed by 4F-PCC or aPCC, TGA parameters exceeded normal range. Further studies are needed to compare the efficacy and safety of a different dose of reversal therapy and the impact on coagulation parameters. [ABSTRACT FROM AUTHOR]

The aim of our study was to compare the time spent within the target INR or Time in Therapeutic Range (TTR) of patients treated with fluindione to that of patients treated with warfarin for non-valvular atrial fibrillation (NVAF) and followed in general practice, with the hypothesis of a better TTR with warfarin, which is the VKA most commonly prescribed in France. Liberal nurses and general practitioners working in the Auvergne region recruited patients treated with fluindione or warfarin for NVAF. Patients' INRs (International Normalized Ratios) were recorded by medical analysis laboratories for 6 months. The primary endpoint was TTR, the secondary endpoint the number of hemorrhagic and/or thromboembolic events. Of the 342 participants with a mean age of 75.3 ± 9.8 years, 239 (70%) were treated with fluindione and 103 (30%) with warfarin. The mean number of INRs achieved per patient was 9.2 ± 4.0 in the fluindione group and 9.3 ± 4.0 in the warfarin group (p=0.73). The median TTR of fluindione was 81.9% [63.5; 94.1] and that of warfarin was 81.3% [65.6; 92.6] (p=0.98). Twenty-eight of 263 patients reported hemorrhage (10.6%) and 4 reported thromboembolic events (0.8%), with no significant difference between the groups. The TTRs of patients treated for NVAF with fluindione versus warfarin do not differ significantly over an observation period of 6 consecutive months in a patient population comparable to that of the publications in this field. However, these TTRs are significantly higher than those reported in the literature, with no difference between the two treatments. The TTRs of patients treated for VANF with fluindione versus warfarin do not differ significantly over a 6-month observation period in a patient population comparable to that of the publications in this indication. [ABSTRACT FROM AUTHOR]

Introduction Presepsin (sCD14-ST) is an emerging biomarker for infection. We hypothesized that presepsin could specifically increase during acute pyelonephritis and correlate with severity. Methods We compared presepsin values in patients with acute pyelonephritis and controls, and we assessed its capacity to predict bacteraemia and admission in patients. Results In 312 patients with acute pyelonephritis (median age 33 years), presepsin concentrations were higher than in controls (476 vs 200 ng/L, p < 0.001). ROC curve indicated an AUC at 0.90 [for presepsin (vs. 0.99 and 0.98 for CRP and PCT, respectively; p < 0.05) and an optimal threshold at 340 ng/L (74% sensitivity, 94% specificity). Presepsin concentrations increased in acute pyelonephritis patients with bacteraemia (614 vs. 461 ng/L, p,=0.001) and in those requiring admission (614 ng/L vs. 320 ng/L, p < 0.001). Performance of presepsin to predict bacteraemia [AUC = 0.63, 95%CI: 0.55–0.72] was similar to CRP (AUC = 0.64, p = 0.87) and less accurate than PCT (AUC = 0.78, p < 0.001). AUC for presepsin to detect the need for admission was 0.67, and comparable to CRP ( p = 0.26) and PCT ( p = 0.18). Conclusion Presepsin is a valuable biomarker to detect patients with acute pyelonephritis. However, it presents mild performance to predict bacteraemia and the need for admission, and offers no advantage as compared to CRP and PCT. [ABSTRACT FROM AUTHOR]

Unlabelled: A low-impact fracture in a postmenopausal woman should prompt investigations for osteoporosis followed, if needed, by appropriate treatment.Objectives: To evaluate the impact of information alerting general practitioners to the need for osteoporosis treatment in postmenopausal women with a recent history of peripheral fracture.Methods: We conducted a prospective 7-month follow-up study of 78 postmenopausal women, with a mean age of 81.5 years, admitted to the emergency department for peripheral fractures. Three months after the fracture, we sent a letter to the general practitioner of each patient emphasizing the probable contribution of osteoporosis to the fracture and the need for osteoporosis treatment. Six months after the fracture, we interviewed the patients by telephone, and one month later we mailed a questionnaire to those physicians who had not followed the treatment recommendation.Results: At emergency room admission, 9 patients were receiving treatment for osteoporosis (hormone replacement therapy in one patient and calcium and vitamin D supplementation in eight patients). Admission to a ward was required in 66 (85%) patients. No treatment for osteoporosis was given at discharge. Six months after discharge, seven patients reported recent initiation of calcium and vitamin D supplementation, and none reported other osteoporosis treatments. The response rate to the physician questionnaire mailed 7 months after discharge was 54% (n=28); responses showed treatment of 11 additional patients, by calcium and vitamin D supplementation in six cases and by bisphosphonates with or without calcium and vitamin D supplementation in five cases. Treatment initiation rates were similar in patients younger and older than 80 years.Conclusions: Despite information of general practitioners about the need for osteoporosis treatment, such treatment was initiated in only 30.5% of patients. General practitioners may be reluctant to initiate osteoporosis treatment in patients who are very old or have multiple comorbidities. [ABSTRACT FROM AUTHOR]

Abstract: A non-traumatic fracture that occurs in a postmenopausal woman should be suspected as osteoporotic and needs a specific intervention. Objectives. – To evaluate the effects of information given to physician on the rate of treatment for osteoporosis initiated after a non-vertebral fracture. Patients and methods. – Seventy-eight postmenopausal women (mean age 81,5 years old) admitted to surgery emergency department with a non-vertebral fracture were studied for seven months. A letter, which informs the physicians that the fracture was probably osteoporotic, and needed a treatment, was sent three months after the fracture occurred. At seven months, a questionnaire was sent to physicians when their patients remained not treated. Results. – Nine patients were receiving a therapy for osteoporosis before the fracture occured: one hormonal replacement therapy and eight calcium (Ca)±vitamin D supplements. Eighty-five percent of the patients were hospitalised, and no treatment was initiated before discharge. At six months, seven treatments were initiated (Ca±vitamin D). At seven months, the answers to questionnaires show that 11 other treatments have been initiated (5 bisphosphonates±Ca/vitamin D et 6 Ca/vitamin D supplements). Management was similar when women where less than 80 years old or 80 and more. Conclusions. – Despite information given to physician, only 30.5% of these patients were offered a treatment for osteoporosis. Was the decision to introduce treatment influence by old age and comorbidities? [Copyright &y& Elsevier]

Abstract: Although elderly people are particularly vulnerable to the adverse effects of alcohol, alcohol use disorders in late life have received relatively little attention in the literature. Our objectives were to assess the prevalence of alcohol use disorders (abuse and dependence), the medical profile and psychosocial characteristics in elderly people visiting emergency department (ED). A cohort of 2405 patients aged over 60 who came to the ED of a university hospital during a 3-month period was studied. Alcohol use disorder diagnosis (DSM-IV), medical profile and social characteristics were collected from retrospective review of patient files. The data derived from 128 patients (mean age, 69.8±6.8 years; 87% males) with alcohol use disorders and 128 non-alcoholic controls. The prevalence of current alcohol use disorder was 5.3%. The most common current alcohol-induced disorders were alcohol intoxication and alcohol-induced mood disorder. Social factors associated with alcohol use disorders were being homeless, living alone, being divorced and never married. Falls and delirium were frequent ED admission circumstances in elderly drinkers. Drinkers more commonly presented with gastrointestinal disorders. In conclusion, alcohol use disorders among older patients admitted in ED are common and occur more frequently among men. Falls and delirium are the main ED admission circumstances in elderly drinkers. Alcohol use disorders are also associated with gastrointestinal problems. [Copyright &y& Elsevier]