[Safety and efficacy profile of anticoagulant therapy in elderly patients discharged from the emergency room with a diagnosis of venous thromboembolic disease: a registry study.] / Profilo di sicurezza ed efficacia della terapia anticoagulante nel paziente anziano dimesso da pronto soccorso con diagnosi di malattia trombo-embolica venosa: uno studio di registro.

BACKGROUND: Venous thromboembolism (Tev), clinically presenting as deep vein thrombosis (Tvp) or pulmonary embolism (EP), is globally the third most frequent acute cardiovascular syndrome. Reported data in literature show that the incidence of Tev is almost eight times higher in individuals aged >80 years than in the fifth decade of life. The mainstay of Tev management is anticoagulation, which should be initiated as soon as possible, provided there is no contraindication and weighing individual potential risks and benefits, in order to prevent further thrombosis and early or late complications. For decades, low molecular weight heparins (Lmwh) and vitamin K antagonists (Vkas) have been the gold standard of anticoagulation. Recently, direct oral anticoagulants (Doacs) revolutionized anticoagulation management in Tev. AIM: This real-world retrospective observational trial evaluated potential differences in safety and efficacy profiles between anticoagulation with Doacs and traditional therapy with Vkas, in the management of acute Tev in elderlies discharged from Emergency Department of Azienda ospedaliera Ordine Mauriziano in Torino. METHODS: A registry of patient evalued by the Doac-Tev ambulatory discharged by ED was compiled and analysed. RESULTS: In the population of this study (186 patients), there was a high compliance to anticoagulation, regardless the therapeutic regimen (Vka vs Doac). There was not a significant difference in the prevalence of mortality, bleeding, unplanned return to Emergency Department and in the composite safety outcome between anticoagulation regimens, with a tendency to higher rates of recurrent Tev in the Vkas group. CONCLUSIONS: A therapy with Doac in discharging elderly patient with Tev is safe and effective.

Combined use of aortic dissection detection risk score and D-dimer in the diagnostic workup of suspected acute aortic dissection.

BACKGROUND: Acute aortic dissection (AD) represents a diagnostic conundrum. Validated algorithms are particularly needed to identify patients where AD could be ruled out without aortic imaging. We evaluated the diagnostic accuracy of a strategy combining the aortic dissection detection (ADD) risk score with D-dimer, a sensitive biomarker of AD. METHODS: Patients from two clinical centers with suspected AD were prospectively enrolled in a registry, from January 2008 to March 2013. The ADD risk score was calculated by retrospective blinded chart review. For D-dimer, a cutoff of 500 ng/ml was applied. RESULTS: AD was diagnosed in 233 of 1035 (22.5%) patients. The ADD risk score was 0 in 322 (31.1%), 1 in 508 (49.1%) and >1 in 205 (19.8%) patients. The sensitivity and the failure rate of D-dimer were 100% and 0% in patients with ADD score 0, versus 97.5% (95% CI 91.4-99.6%) and 4.2% (95% CI 0.7-12.5%) in patients with ADD risk score >1. In patients with ADD risk score ≤ 1, the sensitivity and the failure rate of D-dimer were 98.7% (95% CI 95.3-99.8%) and 0.8% (95% CI 0.1-2.6%). The diagnostic efficiency of D-dimer in patients with ADD risk score 0 and ≤ 1 was 8.9% (95% CI 7.2-10.7%) and 23.6% (95% CI 21.1-26.2%) respectively. CONCLUSIONS: In a large cohort of patients with suspected AD, the presence of ADD risk score 0 or ≤ 1 combined with a negative D-dimer accurately and efficiently ruled out AD.

Diagnostic and prognostic value of presepsin in the management of sepsis in the emergency department: a multicenter prospective study.

INTRODUCTION: Sepsis, severe sepsis and septic shock are common conditions with high mortality. Their early diagnosis in the Emergency Department (ED) is one of the keys to improving survival. Procalcitonin (PCT) has been used as a biomarker in septic patients but has limited specificity and can be elevated in other scenarios of systemic inflammatory response syndrome (SIRS). Soluble CD14 (sCD14) or presepsin is the free fragment of a glycoprotein expressed on monocytes and macrophages. Preliminary reports suggest that levels of presepsin are significantly higher in septic patients than in healthy individuals. The aim of this study is to investigate the diagnostic and prognostic value of presepsin compared to PCT in people presenting at the ED with SIRS and suspected sepsis or septic shock. METHODS: This study was conducted in two major hospitals in Turin, Italy. One hundred six patients presenting to the EDs with suspected sepsis or septic shock were included, and another eighty-three patients affected by SIRS, but with no clinical evidence of infection, were recruited as controls. Blood samples were collected at first medical evaluation and for some patients after 24 and 72 h. The samples were analyzed using the PATHFAST Presepsin assay for sCD14, and commercial kits were used for other determinations (for example, PCT). Definitive diagnosis and survival rates were obtained afterward by analysis of digital medical records. RESULTS: Elevated concentrations of presepsin at presentation were observed in septic patients compared to control patients. The same trend was observed for mean values of PCT. Higher values of presepsin were observed in septic patients at presentation (time 0). The diagnostic accuracy of PCT was generally higher, and areas under the curve (AUCs) were 0.875 for PCT and 0.701 for presepsin. Mean presepsin values were significantly higher in nonsurvivor septic patients (60-day mortality) than in survivors. No significant correlation was noted between PCT and survival. CONCLUSIONS: In our experience, presepsin was useful in the early diagnosis of infection in a complex population of patients with SIRS, sepsis, severe sepsis and septic shock who presented to the ED. Presepsin showed a significant prognostic value, and initial values were significantly correlated with in-hospital mortality of patients affected by sepsis, severe sepsis or septic shock.