Modified Bova score for risk stratification and short-term outcome in acute pulmonary embolism.

INTRODUCTION: Risk stratification in acute pulmonary embolism (PE) is crucial to identify those patients with a poorer prognosis. We aimed to investigate a modified Bova score for risk stratification in acute PE. MATERIALS AND METHODS: We performed a retrospective analysis of PE patients treated in the internal medicine department. Both haemodynamically stable and unstable PE patients, ≥ 18 years with measurements of cardiac troponin I (cTnI) and existing echocardiography were included in the analysis. RESULTS: Data from 130 patients were included for this retrospective analysis. Three patients (2.3%) died in hospital; 84 patients had a Bova score of < 4 points and 46 ≥ 4 points. PE patients with a score ≥ 4 points were older (71.2 ± 13.8 vs. 66.3 ± 15.5 years, p = 0.0733), died more frequently during the in-hospital course (6.5% vs. 0.0%, p = 0.0183), had a more prevalent high-risk PE status (10.9% vs. 1.2%, p = 0.0122), more often had right ventricular dysfunction (100.0% vs. 35.7%, p < 0.000001), presented more frequently with syncope/collapse (21.7% vs. 3.6%, p = 0.00101) and had a higher heart rate (104.6 ± 23.5 vs. 90.0 ± 20.6/min, p = 0.000143), shock index (0.91 ± 0.59 vs. 0.62 ± 0.18, p = 0.000232), cTnI (0.36 ± 0.42 vs. 0.03± 0.10ng/ml, p < 0.000001) and creatinine (1.32 ± 0.50 vs. 1.03 ± 0.27 mg/dl, p = 0.000170). Adjusted multivariate logistic regressions revealed significant associations between the Bova score and in-hospital death (OR 4.172, 95% CI 1.125-15.464, p = 0.0326) as well as pneumonia based on PE-related lung infarction (OR 1.207, 95% CI 1.005-1.449, p = 0.0442). ROC analysis for Bova score predicting in-hospital death and pneumonia based on PE-related lung infarction showed area under the curve values of 0.908 and 0.606 with Bova score cut-off values of 3.5 points and 1.5 points, respectively. CONCLUSIONS: The modified Bova score is highly effective to predict poorer outcome in acute PE.

Cardiac troponin I for predicting right ventricular dysfunction and intermediate risk in patients with normotensive pulmonary embolism.

BACKGROUND: Right ventricular dysfunction (RVD) and cardiac troponin I (cTnI) are important tools for risk stratification in pulmonary embolism (PE). We investigate the association of RVD and cTnI in normotensive PE patients and calculate a cTnI cut-off level for predicting RVD and submassive PE. METHODS: Clinical, laboratory, radiological and echocardiagraphic data were analysed. Patients were categorised into groups with or without RVD and compared focussing on cTnI. Effectiveness of cTnI for predicting RVD and submassive PE was tested. RESULTS: One hundred twenty-nine normotensive PE patients, 71 with and 58 without RVD, were included. Patients with RVD were older (75.0 years (61.3/81.0) vs. 66.0 years (57.7/75.1), P = 0.019). cTnI (0.06 ng/ml (0.02/0.23) vs. 0.01 ng/ml (0.00/0.03), P < 0.0001) and D-dimer values (2.00 mg/l (1.08/4.05) vs. 1.23 mg/l (0.76/2.26), P = 0.016) were higher in PE with RVD. cTnI was associated with RVD (OR 3.95; 95 % CI 1.95-8.02, p = 0.00014). AUC for cTnI diagnosing RVD was 0.79, and for submassive PE0.87. Cut-off values for cTnI predicting RVD and submassive PE were 0.01 ng/ml, with a negative predictive value of 73 %. cTnI was positively correlated with age, D-dimer and creatinine. CONCLUSIONS: In normotensive PE patients, cTnI is helpful for risk stratification and excluding RVD. cTnI elevation is correlated with increasing age and reduced kidney function.

[Gender-specific differences in hemodynamically stable patients with acute pulmonary embolism]. / Geschlechtsspezifische Unterschiede bei hämodynamisch stabilen Patienten mit akuter Lungenarterienembolie.

BACKGROUND AND AIM: Pulmonary embolism (PE) is potentially life-threatening. Aim of this study was to identify genderspecific differences in acute PE and in risk stratification of hemodynamically stable PE patients. METHODS: We analysed retrospectively the data of 129 patients with PE (59.7% women) and compared female and male patients regarding clinical, laboratory and technical parameters. ROC curve and Youden Index were calculated to analyse cardiac troponin I (cTnI) for predicting of right ventricular dysfunction (RVD) and D-Dimer for predicting submassive PE. RESULTS: 129 patients were included in this study. Female patients were older (median 73.0 [25th percentile: 65.0/75th percentile: 81.0] vs. 65.5 [55.2/76.6] years, p = 0.0095) and had more frequent submassive PE (82.7% vs. 64.0%, p = 0.03) with higher systolic pulmonary artery pressure (38.00 ±â€Š18.23 vs. 27.87 ±â€Š17.32 mmHg, p = 0.0018). Multivariable regression analysis showed a strong association between cTnI and RVD (OR, 2.84; 95%CI: 1.52-5.32, p = 0.0011). Association between cTnI and RVD was stronger in male PE patients (OR, 27.67; 95%CI: 3.28-233.31, p = 0.0023) than in female (OR, 1.52; 95%CI: 0.79-2.93, p = 0.21). Area under the curve (AUC) for efficiency of cTnI predicting RVD was higher in male patients (0.92 vs. 0.69). AUC for efficiency of D-Dimer predicting submassive PE was similar in both genders (0.65 vs. 0.62). Genderspecific cTnI cut-off values indicating for RVD, were similar in male and female (> 0.00 vs. > 0.01 ng/ml). D-Dimer values above 1.08 mg/dl in male and 1.41 mg/dl in female indicated for submassive PE. CONCLUSION: Normotensive female PE patients are in mean older and have more frequently submassive PE stadium. cTnI is associated with RVD. cTnI as risk stratification marker for predicting RVD is more effective in male.

Can anterior cruciate ligament reconstruction be performed routinely in day clinic?

Anterior cruciate ligament reconstruction is performed as an outpatient procedure in selected cases. Whether it can be safely performed on a routine basis in day clinic remains unclear. Our hypothesis was that routinely performing outpatient anterior cruciate ligament reconstruction would be equally safe as compared to inpatient procedures. A cohort of 355 patients who underwent outpatient primary reconstruction was analysed at an average follow-up of 3.8 years. Four patients (1.1%) could not be discharged or were readmitted within 24 hours. The 1-month readmission rate was 1.4%. The overall complication rate was 12.1% (43 cases) of which 4.2% (15 patients) occurred within the first 30 days. Performing anterior cruciate ligament reconstructions routinely in day clinic is associated with almost negligible readmission rates and has similar complication rates as for standard in-hospital anterior cruciate ligament reconstructions. Outpatient anterior cruciate ligament reconstructions can therefore be safely performed without specific preoperative patient selection protocols.

[Cyclic vomiting syndrome (CVS) in adults - frequently overlooked?]. / Zyklisches Erbrechenssyndrom (CVS) beim Erwachsenen - eine häufig übersehene Erkrankung?

CVS (cyclic vomiting syndrome) is a functional disorder that can occur in all age groups. Adults typically develop CVS in middle age (around the 35th year of life). CVS is characterised by recurrent stereotypic episodes of nausea and vomiting lasting hours or some days. Between these episodes there are intervals free of symptoms. The main symptoms include nausea, vomiting and often abdominal pain. CVS is a rare disorder in adult patients. Because of the lack of awarness, making the correct diagnosis is not easy und often delayed for some months or years. There is no specific test to secure the diagnosis. The accurate diagnosis is based on the typical anamnestic report and the exclusion of other disorders associated with a recurrent vomiting. No standard evidence-based treatment is currently available either to manage the acute vomiting episode or to manage the prophylactic therapy. For the acute treatment of the vomiting episodes antiemetic, antimigraine and sedative medications were used. The medications frequently used for the prophylactic therapy are amitriptyline and propranolol.

[Stereotypical episodes of vomiting for 11 years in a 33-year-old patient]. / 33-jähriger Patient mit stereotypen Erbrechensepisoden seit 11 Jahren.

A 33-year-old man was admitted because of severe vomiting. For the last 11 years, he had suffered recurrent stereotypical episodes of vomiting lasting 3-4 days. The episodes of vomiting occurred 10-15 times a year. Moreover his brother and his mother had similar symptoms. Thus, (familial) cyclic vomiting syndrome was diagnosed. With the help of antiemetic and sedative drugs, the acute vomiting episode was stopped. Prophylactic therapy with amitriptyline was started, which led to a symptom-free period of 3.5 years without a new episode of vomiting.