Federico Germini

Direct Oral Anticoagulants in Patients With VTE and Cancer

BACKGROUND Direct oral anticoagulants (DOAs) have been shown to be as effective and at least as safe as conventional anticoagulation for the prevention of recurrences in patients with VTE. Whether this is the case in patients with cancer-associated VTE remains undefined. METHODS We performed a meta-analysis of randomized controlled trials with the aim of assessing the efficacy and safety of DOAs in patients with VTE and cancer. MEDLINE, EMBASE, and CENTRAL were searched up to December 2013 with no language restriction. The primary outcome of the analysis was recurrent VTE. Data on major bleeding (MB) and clinically relevant nonmajor bleeding were analyzed. Data were pooled and compared by ORs and 95% CIs. RESULTS Overall, 10 studies comparing DOAs with conventional anticoagulation for treatment of VTE including patients with cancer were included in the review. Six studies were included in the meta-analysis (two with dabigatran, two with rivaroxaban, one with edoxaban, and one with apixaban), accounting for a total of 1,132 patients. VTE recurred in 23 of 595 (3.9%) and in 32 of 537 (6.0%) patients with cancer treated with DOAs and conventional treatment, respectively (OR, 0.63; 95% CI, 0.37-1.10; I2, 0%). MB occurred in 3.2% and 4.2% of patients receiving DOAs and conventional treatment, respectively (OR, 0.77; 95% CI, 0.41-1.44; I2, 0%). CONCLUSIONS DOAs seem to be as effective and safe as conventional treatment for the prevention of VTE in patients with cancer. Further clinical trials in patients with cancer-associated VTE should be performed to confirm these results.

Computed tomography to assess risk of death in acute pulmonary embolism: a meta-analysis

The aim of this study was to evaluate whether right ventricle dilation at computed tomography (CT) angiography can be used to assess the risk of death in patients with acute pulmonary embolism. Medline and EMBASE were searched up to April 30, 2013. Studies reporting on the association between right ventricle dilation (right-to-left ventricle diameter) or dysfunction (inter-ventricular septal bowing) at CT angiography and death at 30 days, as well as at 3 months in patients with acute pulmonary embolism, were included in a systematic review and meta-analysis. CT-detected right ventricle dilation was associated with an increased 30 day-mortality in all-comers with pulmonary embolism (OR 2.08 (95% CI 1.63–2.66); p<0.00001) and in haemodynamically stable patients (OR 1.64 (95% CI 1.06–2.52); p=0.03), as well as with death due to pulmonary embolism (OR 7.35 (95% CI 3.59–15.09); p<0.00001). An association between right ventricle dilation and 3-month mortality was also observed (OR 4.65 (95% CI 1.79–12.07); p=0.002). Right-to-left ventricle dilation as assessed by CT angiography can be used to evaluate risk of death in all-comers with pulmonary embolism and in haemodynamically stable patients. Multidetector CT can be used to assess short-term risk of death in patients with acute pulmonary embolism http://ow.ly/sNcBU

Prognostic role of embolic burden assessed at computed tomography angiography in patients with acute pulmonary embolism: systematic review and meta‐analysis

In patients with acute pulmonary embolism (PE), risk stratification is indicated for tailoring of both diagnostic strategies and acute treatment. Whether embolic burden assessed at computed tomography (CT) angiography has a role in risk stratification in these patients is debated.

Predicting risk and outcomes for frail older adults: an umbrella review of frailty screening tools

Background A scoping search identified systematic reviews on diagnostic accuracy and predictive ability of frailty measures in older adults. In most cases, research was confined to specific assessment measures related to a specific clinical model. Objectives To summarize the best available evidence from systematic reviews in relation to reliability, validity, diagnostic accuracy and predictive ability of frailty measures in older adults. Inclusion criteria Population Older adults aged 60 years or older recruited from community, primary care, long-term residential care and hospitals. Index test Available frailty measures in older adults. Reference test Cardiovascular Health Study phenotype model, the Canadian Study of Health and Aging cumulative deficit model, Comprehensive Geriatric Assessment or other reference tests. Diagnosis of interest Frailty defined as an age-related state of decreased physiological reserves characterized by an increased risk of poor clinical outcomes. Types of studies Quantitative systematic reviews. Search strategy A three-step search strategy was utilized to find systematic reviews, available in English, published between January 2001 and October 2015. Methodological quality Assessed by two independent reviewers using the Joanna Briggs Institute critical appraisal checklist for systematic reviews and research synthesis. Data extraction Two independent reviewers extracted data using the standardized data extraction tool designed for umbrella reviews. Data synthesis Data were only presented in a narrative form due to the heterogeneity of included reviews. Results Five reviews with a total of 227,381 participants were included in this umbrella review. Two reviews focused on reliability, validity and diagnostic accuracy; two examined predictive ability for adverse health outcomes; and one investigated validity, diagnostic accuracy and predictive ability. In total, 26 questionnaires and brief assessments and eight frailty indicators were analyzed, most of which were applied to community-dwelling older people. The Frailty Index was examined in almost all these dimensions, with the exception of reliability, and its diagnostic and predictive characteristics were shown to be satisfactory. Gait speed showed high sensitivity, but only moderate specificity, and excellent predictive ability for future disability in activities of daily living. The Tilburg Frailty Indicator was shown to be a reliable and valid measure for frailty screening, but its diagnostic accuracy was not evaluated. Screening Letter, Timed-up-and-go test and PRISMA 7 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) demonstrated high sensitivity and moderate specificity for identifying frailty. In general, low physical activity, variously measured, was one of the most powerful predictors of future decline in activities of daily living. Conclusion Only a few frailty measures seem to be demonstrably valid, reliable and diagnostically accurate, and have good predictive ability. Among them, the Frailty Index and gait speed emerged as the most useful in routine care and community settings. However, none of the included systematic reviews provided responses that met all of our research questions on their own and there is a need for studies that could fill this gap, covering all these issues within the same study. Nevertheless, it was clear that no suitable tool for assessing frailty appropriately in emergency departments was identified.

Efficacy and safety of direct oral anticoagulants after pulmonary embolism: A meta-analysis

tively (OR 0.89, 95% CI 0.70–1.12; I-squared 0%) (Fig. 1). A similar efficacy profile was observed for the anti-Xa agents (OR 0.89, 95% CI 0.69–1.15, I-squared 20%) and for dabigatran (OR 0.87, 95% CI 0.46– 1.64). The analysis based on the single-drug approach [3,6] or the heparin/direct oral anticoagulants approach [2,4,5] showed an OR of 1.05 (95% CI 0.75–1.48, I-squared 0%) and OR 0.76 (95% CI 0.55–1.05, I-squared 0%) respectively.

Quality of reporting in abstracts of RCTs published in emergency medicine journals: a protocol for a systematic survey of the literature

Introduction The quality of reporting of abstracts of randomised controlled trials (RCTs) in major general medical journals and in some category-specific journals was shown to be poor before the publication of the ConsolidatedStandards of ReportingTrials (CONSORT) extension for abstracts in 2008, and an improvement in the quality of reporting of abstracts was observed after its publication. The effect of the publication of the CONSORT extension for abstracts on the quality of reporting of RCTs in emergency medicine journals has not been studied. In this paper, we present the protocol of a systematic survey of the literature, aimed at assessing the quality of reporting in abstracts of RCTs published in emergency medicine journals and at evaluating the effect of the publication of the CONSORT extension for abstracts on the quality of reporting. Methods and analysis The Medline database will be searched for RCTs published in the years 2005–2007 and 2014–2015 in the top 10 emergency medicine journals, according to their impact factor. Candidate studies will be screened for inclusion in the review. Exclusion criteria will be the following: the abstract is not available, they are published only as abstracts, still recruiting, or duplicate publications. The study outcomes will be the overall quality of reporting (number of items reported) according to the CONSORT extension and the compliance with its individual items. Two independent reviewers will screen each article for inclusion and will extract data on the CONSORT items and on other variables, which can possibly affect the quality of reporting. Ethics and dissemination This is a library-based study and therefore exempt from research ethics board review. The review results will be disseminated through abstract submission to conferences and publication in a peer-reviewed biomedical journal.

COPD exacerbations in the emergency department: Epidemiology and related costs. A retrospective cohort multicentre study from the Italian Society of Emergency Medicine (SIMEU)

Acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) frequently cause patients with COPD to access the emergency department and have a negative impact on the course of the disease. The objectives of our study were: 1) describing the socio-demographic and clinical characteristics, and the clinical management, of patients with AECOPD, when they present to the emergency department; and 2) estimating the costs related to the management of these patients. We conducted a retrospective cohort study in Italy, collecting data on 4396 patients, from 34 centres. Patients had a mean (SD) age of 76,6 (10.6) years, and 61.2% of them where males. >70% of the patients had a moderate to very high comorbidity burden, and heart failure was present in 26.4% of the cohort. The 64.6% of patients were admitted to hospital wards, with a mean (SD) length of stay of 10.8 (9.8) days. The estimated cost per patient was 2617 €. CONCLUSIONS Patients attending the ED for an AECOPD are old and present important comorbidities. The rate of admission is high, and costs are remarkable.

Emergency physician accuracy in interpreting electrocardiograms with potential ST-segment elevation myocardial infarction: Is it enough?

Background: Electrocardiogram (ECG) interpretation is widely performed by emergency physicians. We aimed to determine the accuracy of interpretation of potential ST-segment elevation myocardial infarction (STEMI) ECGs by emergency physicians. Methods: Thirty-six ECGs resulted in putative STEMI diagnoses were selected. Participants were asked to focus on whether or not the ECG in question met the diagnostic criteria for an acutely blocked coronary artery causing a STEMI. Based on the coronary angiogram, a binary outcome of accurate versus inaccurate ECG interpretation was defined. We computed the overall sensitivity, specificity, accuracy and 95% confidence intervals (95%CIs) for ECG interpretation. Data on participant training level, working experience and place were collected. Results: 135 participants interpreted 4603 ECGs. Overall sensitivity to identify ‘true’ STEMI ECGs was 64.5% (95%CI: 62.8–66.3); specificity in determining ‘false’ ECGs was 78% (95%CI: 76–80.1). Overall accuracy was modest (69.1, 95%CI: 67.8–70.4). Higher accuracy in ECG interpretation was observed for attending physicians, participants working in tertiary care hospitals and those more experienced. Conclusion: The accuracy of interpretation of potential STEMI ECGs was modest among emergency physicians. The study supports the notion that ECG interpretation for establishing a STEMI diagnosis lacks the necessary sensitivity and specificity to be considered a reliable ‘stand-alone’ diagnostic test.

Predicting risk and outcomes for frail older adults: results of an umbrella review of available screening tools for frailty

Background: Frailty is an age-related state of high vulnerability to adverse health outcomes after a stressor event, predisposing individuals to progressive decline in different functional domains and contributing to the onset of geriatric syndromes. Several assessment tools had their psychometric properties analysed in different systematic reviews (SRs). This study syntheses the existing evidence through an umbrella review (UR), developed within the context of the project “664367/FOCUS” funded under the European Unions Health Programme (2014–2020). Objective: To summarize the best available evidence from SRs on available measures to identify frailty in older adults, focusing on (i) their reliability, validity, and diagnostic accuracy in detecting the frail condition; (ii) their ability to predict adverse health outcomes. Methods: The review process was based on Joanna Briggs Institute procedures regarding URs. The studies considered as eligible for inclusion were quantitative SRs including older adults aged 60 years or more, recruited from any type of setting (primary care, long-term residential care, hospitals). The index tests were currently available screening tools for frailty in older adults. In addition, frailty indicators were considered. Tests from the Cardiovascular Health Study and the Canadian Study of Health and Aging, as well as other recognised gold standards were used as reference tests. Diagnosis of interest was frailty. Databases were searched from January 2001 to October 2015. Results: 10 SRs were appraised for methodological quality, and 6 SRs describing 25 screening tools and 7 frailty indicators were included. Based on evidence regarding capacity to detect frail condition, gait speed, Screening Letter, Timed get-up-and-go Test and PRISMA 7 appeared as potentially relevant for screening for frailty in a primary care setting. Tilburg Frailty Indicator was revealed to be the most reliable and valid measure (acceptable internal consistency, inter-rater reliability and concomitant validity). Frailty Index and two frailty indicators (gait speed and physical activity) were shown to be the most powerful predictors of future adverse health outcomes. Discussion: The most frequent limitations of 10 SRs were related to inappropriate definition of inclusion criteria, lack of a reference standard and lack of, or inappropriate tool used for critical appraisal of the included studies. In addition, lack of uniformity of provided statistics, and inconsistency in conferring significance to obtained results were observed. Almost all frailty indicators (with exception of gait speed) were not operationalized. Evidence compiled by this UR suggests that gait speed is the only measure that is sufficiently sensitive to identify frailty in older adults and, simultaneously, sufficiently accurate to predict increased risk of adverse outcome. However, because of limited specificity, its use in routine care should be accompanied by other instruments. Conclusion: The evidence showed that none of the analysed index tests has enough quality to be used as a single screening tool. There is a need for user-friendly instruments to identify frailty in older adults. Regarding predictive ability, Frailty Index, gait speed and physical activity can be used as single measures. Future studies focused on instruments for frailty should be more rigorous on methodology to improve the quality of obtained evidence.