Gregor John

Systemic thrombolytic therapy for acute pulmonary embolism: a systematic review and meta-analysis

Aim Thrombolytic therapy induces faster clot dissolution than anticoagulation in patients with acute pulmonary embolism (PE) but is associated with an increased risk of haemorrhage. We reviewed the risks and benefits of thrombolytic therapy in the management of patients with acute PE. Methods and results We systematically reviewed randomized controlled studies comparing systemic thrombolytic therapy plus anticoagulation with anticoagulation alone in patients with acute PE. Fifteen trials involving 2057 patients were included in our meta-analysis. Compared with heparin, thrombolytic therapy was associated with a significant reduction of overall mortality (OR; 0.59, 95% CI: 0.36–0.96). This reduction was not statistically significant after exclusion of studies including high-risk PE (OR; 0.64, 95% CI: 0.35–1.17). Thrombolytic therapy was associated with a significant reduction in the combined endpoint of death or treatment escalation (OR: 0.34, 95% CI: 0.22–0.53), PE-related mortality (OR: 0.29; 95% CI: 0.14–0.60) and PE recurrence (OR: 0.50; 95% CI: 0.27–0.94). Major haemorrhage (OR; 2.91, 95% CI: 1.95–4.36) and fatal or intracranial bleeding (OR: 3.18, 95% CI: 1.25–8.11) were significantly more frequent among patients receiving thrombolysis. Conclusions Thrombolytic therapy reduces total mortality, PE recurrence, and PE-related mortality in patients with acute PE. The decrease in overall mortality is, however, not significant in haemodynamically stable patients with acute PE. Thrombolytic therapy is associated with an increase of major and fatal or intracranial haemorrhage.

Urinary incontinence as a marker of higher mortality in patients receiving home care services

To evaluate urinary incontinence (UI) as a predictor of nursing home admission, hospitalization or death in patients receiving home care services.

Urinary Incontinence as a Predictor of Death: A Systematic Review and Meta-Analysis.

Background The association between urinary incontinence (UI) and increased mortality remains controversial. The objective of our study was to evaluate if this association exists. Methods We performed a systematic review and meta-analysis of observational studies comparing death rates among patients suffering from UI to those without incontinence. We searched in Medline, Embase and the Cochrane library using specific keywords. Studies exploring the post-stroke period were excluded. Hazard ratios (HR) were pooled using models with random effects. We stratified UI by gender and by UI severity and pooled all models with adjustment for confounding variables. Results Thirty-eight studies were retrieved. When compared to non-urinary incontinent participants, UI was associated with an increase in mortality with pooled non adjusted HR of 2.22 (95%CI 1.77–2.78). The risk increased with UI severity: 1.24 (95%CI: 0.79–1.97) for light, 1.71 (95%CI: 1.26–2.31) for moderate, and 2.72 (95%CI: 1.90–3.87) for severe UI respectively. When pooling adjusted measures of association, the resulting HR was 1.27 (95%CI: 1.13–1.42) and increased progressively for light, moderate and severe UI: 1.07 (95%CI: 0.79–1.44), 1.25 (95%CI: 0.99–1.58), and 1.47 (95%CI: 1.03–2.10) respectively. There was no difference between genders. Conclusion UI is a predictor of higher mortality in the general and particularly in the geriatric population. The association increases with the severity of UI and persists when pooling models adjusted for confounders. It is unclear if this association is causative or just reflects an impaired general health condition. As in most meta-analyses of observational studies, methodological issues should be considered when interpreting results.

Urinary incontinence as a predictor of death after new-onset stroke: a meta-analysis

Urinary incontinence (UI) could be an indicator of increased mortality after new‐onset stroke. The aim of the present meta‐analysis was to characterize this association.

Hemodynamic indexes derived from computed tomography angiography to predict pulmonary embolism related mortality.

Pulmonary embolism (PE) induces an acute increase in the right ventricle afterload that can lead to right-ventricular dysfunction (RVD) and eventually to circulatory collapse. Hemodynamic status and presence of RVD are important determinants of adverse outcomes in acute PE. Technologic progress allows computed tomography angiography (CTA) to give more information than accurate diagnosis of PE. It may also provide an insight into hemodynamics and right-ventricular function. Proximal localization of emboli, reflux of contrast medium to the hepatic veins, and right-to-left short-axis ventricular diameter ratio seem to be the most relevant CTA predictors of 30-day mortality. These elements require little postprocessing time, an advantage in the emergency room. We herein review the prognostic value of RVD and other CTA mortality predictors for patients with acute PE.

Tobacco-stained fingers: a clue for smoking-related disease or harmful alcohol use? A case-control study.

Objective Tobacco stain on fingers is frequent. However, there is scarce description of this clinical sign. We aimed to explore tobacco stain on fingers as a marker of tobacco-related disease independent of cumulative tobacco exposure, and to find behavioural and environmental characteristics associated with those stains. Design Case–control study. Setting A Swiss community hospital of 180 beds. Participants 49 adults presenting tobacco-tars staining on fingers were matched to 49 control smokers by age, gender, height and pack-year (PY). Outcome measures Documented smoking-related carcinoma, ischaemic heart disease, peripheral arterial disease, stroke and chronic obstructive pulmonary disease (COPD), also determined by lung function, were compared between groups. Association between harmful alcohol use, mental disorders or unemployment and tar-staining was adjusted for smoking behaviour through conditional logistic regression. Results Overall cigarette-related disease was high in the case group (84%), and symptomatic peripheral arterial disease was more frequent compared to controls (OR 3.5, CI 95% 1.1 to 14.6). Smoking-related carcinoma, ischaemic heart disease, stroke and COPD were not statistically different for control smokers. Harmful alcohol use was strongly associated with stains and this association persists after adjustment for smoking unfiltered cigarettes, smoking more than one pack of cigarettes in a day and age at smoking onset (adjusted OR 4.6, CI 95% 1.2 to 17.2). Mental disorders and unemployment were not statistically significant. Conclusions Patients with tobacco-tar-stained fingers frequently have cigarette-related disease, however statistically not more than control smokers matched for PY, except for symptomatic peripheral arterial disease. This study suggests a link between stained fingers and addictive behaviour or concomitant high alcohol consumption.

Time to antibiotics administration and outcome in community-acquired pneumonia: Secondary analysis of a randomized controlled trial

BACKGROUND The association between early antibiotic administration and outcomes remains controversial in patients hospitalized for community-acquired pneumonia. METHODS We performed a secondary analysis of a randomized controlled trial comparing two antibiotic treatment strategies for patients hospitalized for moderately severe CAP. The univariate and multivariate associations between time to antibiotic administration (TTA) and time to clinical stability were assessed using a Cox proportional hazard model. Secondary outcomes were death, intensive care unit admission and hospital readmission up to 90days. RESULTS 371 patients (mean age 76years, CURB-65 score≥2 in 52%) were included. Mean TTA was 4.35h (SD 3.48), with 58.5% of patients receiving the first antibiotic dose within 4h. In multivariate analysis, number of symptoms and signs (HR 0.876, 95% CI 0.784-0.979, p=0.020), age (HR 0.986, 95% CI 0.975-0.996, p=0.007), initial heart rate (HR 0.992, 95% CI 0.986-0.999, p=0.023), and platelets count (HR 0.998, 95% CI 0.996-0.999, p=0.004) were associated with a reduced probability of reaching clinical stability. The association between TTA and time to clinical stability was not significant (HR 1.009, 95% CI 0.977-1.042, p=0.574). We found no association between TTA and the risk of intensive care unit admission, death or readmission up to 90days after the initial admission. CONCLUSION In patients hospitalized for moderately severe CAP, a shorter time to antibiotic administration was not associated with a favorable outcome. These findings support the current recommendations that do not assign a specific time frame for antibiotics administration.

Urinary Incontinence and Indwelling Urinary Catheters as Predictors of Death after New-Onset Stroke: a Report of the South London Stroke Register

OBJECTIVE To explore the relationship between indwelling urinary catheters (IUCs), urinary incontinence (UI), and death in the poststroke period and to determine when, after the neurological event, UI has the best ability to predict 1-year mortality. METHODS In a prospective observational study, 4477 patients were followed up for 1 year after a first-ever stroke. The impact of UI or urinary catheters on time to death was adjusted in a Cox model for age, sex, Glasgow Coma Scale, prestroke and poststroke Barthel Index, swallow test, motor deficit, diabetes, and year of inclusion. The predictive values of UI assessed at the maximal deficit or 7 days after a stroke were compared using receiver-operating curves. RESULTS UI at the maximal neurological deficit and urinary catheters within the first week after the stroke were present in 43.9% and 31.2% patients, respectively. They were both associated with 1-year mortality in unadjusted and adjusted analysis (hazard ratio [HR], 1.78, 95% confidence interval [CI], 1.46-2.19, and HR, 1.84, 95% CI 1.54-2.19). Patients with UI and urinary catheters had twice the mortality rate of incontinent patients without urinary catheters (HR, 10.24; 95% CI, 8.72-12.03 versus HR, 4.70; 95% CI, 3.88-5.70; P < .001). UI assessed after 1 week performed better at predicting 1-year mortality than UI assessed at the maximal neurological deficit. CONCLUSION IUCs in the poststroke period is associated with death, especially among incontinent patients. UI assessed at 1 week after the neurological event has the best predictive ability.

The limited cutaneous form of systemic sclerosis is associated with urinary incontinence: an international multicentre study

Objectives The aim of this study was to explore the association between urinary incontinence (UI) and the main clinical and serological subsets of SSc, to assess risk factors for UI and its impact on quality of life (QoL). Methods UI and QoL were assessed through self-administered questionnaires in 334 patients with SSc from five European tertiary centres. Logistic regressions were performed to test the association between clinical forms, serological status and UI and to adjust for confounders. Further independent predefined SSc risk factors for UI were tested through a multivariable logistic model. Results The prevalence of UI was 63% (95% CI: 60, 68%). lcSSc and ACAs were both significantly associated with UI even after adjusting for age, sex, disability, diabetes, BMI, caffeine consumption, dyspnoea, faecal incontinence, abnormal bowel movement, presence of overlapping rheumatological disease and pulmonary hypertension [adjusted odds ratio (OR) = 2.4; 95% CI: 1.2, 4.7]. ACA and lcSSc doubled the risk of frequent and heavy urinary leaks. Factors independently associated with UI were as follows: lcSSc (OR = 2.2; 95% CI: 1.1, 3.2), ACA (OR = 2.8; 95% CI: 1.4, 5.8), female sex (OR = 10.8; 95% CI: 2.8, 41.3), worsening of dyspnoea (OR = 6.8; 95% CI: 1.2, 36.7), higher HAQ-DI (OR = 3.2; 95% CI: 1.5, 6.7), BMI (OR = 1.1; 95% CI: 1.0, 1.1) and active finger ulceration (OR = 0.3; 95% CI: 0.1, 0.7). Patients suffering from UI had decreased QoL. Conclusion Self-reported UI is frequent in SSc and disproportionally affects the limited cutaneous form of the disease and patients positive for ACA. Trial registration ClinicalTrials.gov, http://clinicaltrials.gov, NCT01971294.

Contrast Circulation Time to Assess Right Ventricular Dysfunction in Pulmonary Embolism: A Retrospective Pilot Study.

Objective To optimize enhancement of pulmonary arteries and facilitate diagnosis of pulmonary embolism (PE), modern computed tomography angiography (CTA) contains a contrast bolus tracking system. We explored the diagnostic accuracy of the time-intensity curves given by this automated system to identify right ventricular dysfunction (RVD) in acute PE. Methods 114 CTAs with a diagnosis of PE were reviewed. RVD was defined as right-to-left ventricular diameter ratio of 1 or greater. Four parameters on time-intensity curves were identified. Parameters between CTAs with and those without RVD were compared with the Wilcoxon rank-sum test. The ability of the four parameters to discriminate patients with RVD was explored by compiling the area under the operating curves (AUC). Results The time needed by the contrast media to reach the pulmonary artery [8 seconds (IQR: 7–9) versus 7 seconds (IQR: 6–8), p<0.01], the time needed to reach 40 Hounsfield units (HU) [11 seconds (IQR: 8.5–14) versus 9.5 seconds (IQR: 8–10.5), p<0.01], and the contrast intensity reached after 10 seconds [19 HU (IQR: 4–67) versus 53 HU (IQR: 32–80), p<0.05] were all statistically different between CTA with and CTA without RVD. Those three parameters changed gradually across severity categories of RVD (p<0.05 for trend). Their AUC to identify RVD ranged from 0.63 to 0.66. The slope of contrast intensity over time was not informative: [31 HU/s (IQR: 20–57) in CTA with, compared to 36 HU/s (IQR: 22.5–53) in CTA without RVD, p = 0.60]. Conclusion Several parameters of the time-intensity curve obtained by the bolus tracking system are associated with RVD assessed on CTA images. Of those, the time needed to reach a predefined threshold seems to be the easiest to obtain in any CTA without additional processing time or contrast injection. However, the performance of those parameters is globally low.