Comorbidity burden conditions the prognostic performance of D-dimer in elderly patients with acute pulmonary embolism.

INTRODUCTION: The prognostic accuracy of D-dimer for risk assessment in acute Pulmonary Embolism (APE) patients may be hampered by comorbidities. We investigated the impact of comorbidity burden (CB) by using the Charlson Comorbidity Index (CCI), on the prognostic ability of D-dimer to predict 30 and 90-day mortality in hemodynamically stable elderly patients with APE. METHODS: All patients aged >65 years with normotensive APE, consecutively evaluated in the Emergency Department since 2010 through 2014 were included in this retrospective cohort study. Area under the curve (AUC) and ½ Net Reclassification Improvement (NRI) were calculated. RESULTS: Study population: 162 patients, median age: 79.2 years. The optimal cut-off value of CCI score for predicting mortality was ≤1 (Low CB) and >1 (High CB), AUC = 0.786. Higher levels of D-dimer were associated with an increased risk death at 30 (HR = 1.039, 95%CI:1.000-1.080, p = 0.049) and 90 days (HR = 1.039, 95%CI:1.009-1.070, p = 0.012). When added to simplified Pulmonary Embolism Severity Index (sPESI) score, D-dimer increased significantly the AUC for predicting 30-day mortality in Low CB (AUC = 0.778, 95%CI:0.620-0.937, ½NRI = 0.535, p = 0.015), but not in High CB patients (AUC = 0.634, 95%CI:0.460-0.807, ½ NRI = 0.248, p = 0.294). Similarly, for 90-day mortality D-dimer increased significantly the AUC in Low CB (AUC = 0.786, 95%CI:0.643-0.929, ½NRI = 0.424, p-value = 0.025), but not in High CB patients (AUC = 0.659, 95%CI:0.541-0.778, ½NRI = 0.354, p-value = 0.165). CONCLUSION: In elderly patients with normotensive APE, comorbidities condition the prognostic performance of D-dimer, which was found to be a better predictor of death in subjects with low CB. These results support multimarker strategies for risk assessment in this population.

Padua prediction score and IMPROVE score do predict in-hospital mortality in Internal Medicine patients.

Padua prediction score (PPS) and IMPROVE bleeding score are validated tools for venous thromboembolism (VTE) risk assessment recommended by guidelines, albeit not frequently used. Some data suggest that a positive PPS and IMPROVE score may be were associated with early mortality in Internal Medicine patients. Aim of the study was to characterize the predictive ability on mortality of the two scores using two different populations, respectively, as derivation and validation cohort. The derivation cohort consisted of 1956 Internal Medicine patients admitted to La Spezia Hospital in 2013. 399 Internal Medicine patients admitted to Carate Brianza Hospital in 2016 constituted the validation cohort. PPS and IMPROVE scores were applied to each patient using their validated cutoffs. Frequency of positive PPS and mortality were significantly higher in La Spezia patients. In the derivation cohort, the positivity of at least one of the two scores was associated with a significantly higher mortality compared to both negative scores. Similar results were observed in the validation cohort. In the derivation cohort, the sensitivity of a positive PPS score in predicting mortality was 0.97 (0.94, 0.98) but the specificity was 0.21 (0.19, 0.23), the negative likelihood ratio being 0.15. Sensitivity and specificity of a positive IMPROVE gave specular findings but the positive likelihood ratio was 2.19. The accuracy data in the validation cohort were in the same direction. Both PPS and IMPROVE are associated with in-hospital mortality but their additional predictive accuracy is modest. It is unlikely that both scores could be useful in clinical practice to predict death in hospitalized Internal Medicine patients.

Short and long-term mortality in elderly patients with suspected not confirmed pulmonary embolism.

INTRODUCTION: Most patients evaluated for suspected pulmonary embolism(PE) conclude the Emergency Department(ED) work-up with a diagnosis of PE not confirmed(PE excluded;PE-E). We aimed to investigate the clinical features, short and long-term mortality, and prognostic factors for death in elderly with PE-E, and to compare these figures with those of patients with PE confirmed(PE-C). METHODS: Consecutive patients ≥65 years old evaluated in the ED for clinically suspected hemodynamically stable acute PE were included in this retrospective cohort study. RESULTS: Study population: 657 patients with suspected PE, PE-C:162(24.65%). When compared with PE-C, patients with PE-E presented a higher prevalence of chronic cardiopulmonary disease (17.37% vs 8.02%, p = 0.003), a lower prevalence of pulse rate >110 (13.13% vs 25.93%; p<0.001), of arterial oxygen saturation <90% (16.16% vs. 25.93%; p = 0.007) and of hospitalized patients (52.93% vs 98.15%; p < 0.001). Thirty-day, 90-day, 1-year, 2-year and 5-year overall mortality was 8.83%, 15.98%, 23.59%, 29.68%, and 51.09%, respectively, differences between PE-E and PE-C non statistically significant. Among patients with PE-E, multivariate analysis showed that simplified Pulmonary Embolism Severity Index score>0 was associated with higher short and long-term mortality (30-day:HR:5.31,p = 0.029; 5 year:HR:2.18, p < 0.001), meanwhile comorbidity (Charlson Comorbidity Index>0) only with higher long-term mortality (30-day: HR:1.60, p = 0.342; 5 year: HR:1.41, p = 0.038). CONCLUSION: In real world haemodinamically stable elderly patients evaluated in the ED for suspected PE, short and long-term mortality was markedly high regardless whether PE was confirmed or excluded. At the time to set management and follow up strategies, elderly patients with PE excluded should not be considered a low-risk population.

Maxillary tooth splinting in periodontally compromised patients using fiber-reinforced composite: the Targis-Vectris method.

AIM: To show the Targis-Vectris retention technique, illustrating its features and clinical applications in periodontally compromised patients. METHODS: The Targis-Vectris technique is constituted by an esthetic external layer (Targis) combined with and supported by a metal-free structure (Vectris). An adult female with a full Class II malocclusion and compromised periodontal condition with significant bone loss on the maxillary central incisor was treated. Before debonding, a fiber-reinforced splint was placed on the palatal surface of the maxillary anterior teeth, using the Targis-Vectris method, to permit long-term stability. The final result remained stable at 5 years posttreatment. RESULTS: The correction of the Class II malocclusion took 24 months. The Targis-Vectris method ensured maintenance of tooth position and periodontal condition. CONCLUSION: The Targis-Vectris technique represents a useful procedure for splinting maxillary teeth in selected periodontally compromised patients. The 5-year posttreatment follow-up visit showed no relapse. Correct occlusal relationships are necessary to reduce the risk of breakage.