Analysis of Clinical and Laboratory Risk Factors of Post-Traumatic Intracranial Hemorrhage in Patients on Direct Oral Anticoagulants with Mild Traumatic Brain Injury: An Observational Multicenter Cohort.

BACKGROUND: Assessing the risk of intracranial hemorrhage (ICH) in patients with a mild traumatic brain injury (MTBI) who are taking direct oral anticoagulants (DOACs) is challenging. Currently, extensive use of computed tomography (CT) is routine in the emergency department (ED). OBJECTIVE: This study aims to investigate whether the clinical and laboratory characteristics presented at the ED evaluation can also estimate the risk of post-traumatic ICH in DOAC-treated patients with MTBI. METHODS: A retrospective observational study was conducted in three EDs in Italy from January 1, 2016 to March 15, 2020. All patients treated with DOACs who were evaluated for an MTBI in the ED were enrolled. The primary outcome of the study was the presence of post-traumatic ICH in the head CT performed in the ED. RESULTS: Of 930 patients on DOACs with MTBI who were enrolled, 6.8% (63 of 930) had a post-traumatic ICH and 1.5% (14 of 930) were treated with surgery or died as a result of the ICH. None of the laboratory factors were associated with an increased risk of ICH. On multivariate analysis, previous neurosurgical intervention, major trauma dynamic, post-traumatic loss of consciousness, post-traumatic amnesia, Glasgow Coma Scale score of 14, and evidence of trauma above the clavicles were associated with a higher risk of post-traumatic ICH. The net clinical benefit provided by risk factor assessment appears superior to the strategy of performing CT on all DOAC-treated patients. CONCLUSIONS: Assessment of the clinical characteristics presented at ED admission can help identify DOAC-treated patients with MTBI who are at risk of ICH.

Risk factors associated with intracranial bleeding and neurosurgery in patients with mild traumatic brain injury who are receiving direct oral anticoagulants.

BACKGROUND: The established clinical risk factors for post-traumatic intracranial bleeding have not been evaluated in patients receiving DOACs yet. AIM: Evaluating the association between clinic and patient characteristics and post-traumatic intracranial bleeding (ICH) in patients with mild traumatic brain injury (MTBI) and DOACs. METHODS: This is a retrospective observational study conducted on three Emergency Departments. Multivariate analysis provided association in terms of OR with the risk of ICH. The performance of the multivariate model, described in a nomogram, has been tested with discrimination and decision curve analysis. RESULTS: Of 473 DOACs patients with MTBI, 8.5% had post-traumatic ICH. On multivariable analysis, major dynamics (odds ratio [OR] 6.255), post-traumatic amnesia (OR 3.961), post-traumatic loss of consciousness (LOC, OR 7.353), Glasgow Coma Scale (GCS) score < 15 (OR 3.315), post-traumatic headache (OR 4.168) and visible trauma above the clavicles (OR 3.378) were associated with a higher likelihood of ICH. The multivariate model, used for the nomogram construction, showed a good performance (AUC bias corrected with 5000 bootstraps resample 0.78). The DCAs showed a net clinical benefit of the prognostic model. CONCLUSIONS: Clinical risk factors can be used in DOACs patients to better define the risk of post-traumatic ICH.

Direct Oral Anticoagulant Treatment and Mild Traumatic Brain Injury: Risk of Early and Delayed Bleeding and the Severity of Injuries Compared with Vitamin K Antagonists.

BACKGROUND: The risk of intracranial hemorrhage (ICH) in patients taking direct oral anticoagulants (DOACs) after mild traumatic brain injury (MTBI) is unclear. OBJECTIVES: To assess the differences in the risk of developing early, delayed, and comprehensive bleeding after MTBI among patients treated with DOACs as compared with those treated with vitamin K antagonists (VKAs). METHODS: All MTBI patients taking oral anticoagulants in our emergency department between June 2017 and August 2018 were included. All patients on oral anticoagulants underwent immediate cerebral computed tomography (CT) and a second CT scan after 24 h of clinical observation. RESULTS: There were 451 patients enrolled: 268 were on VKAs and 183 on DOACs. Of the DOAC-treated patients, 7.7% (14/183) presented overall intracranial bleeding, compared with 14.9% (40/268) of VKA-treated patients (p = 0.026). Early bleeding was present in 5.5% (10/183) of DOAC-treated patients and in 11.6% (31/268) of VKA-treated patients (p = 0.030). Multivariable analysis showed that VKA therapy (odds ratio [OR] 2.327), high-energy impact (OR 11.229), amnesia (OR 2.814), loss of consciousness (OR 5.286), Glasgow Coma Scale score < 15 (OR 4.719), and the presence of lesion above the clavicles (OR 2.742) were associated with significantly higher risk of global ICH. A nomogram was constructed to predict ICH using these six variables. Discrimination of the nomogram revealed good predictive abilities (area under the receiver operating characteristic curve: 0.817). CONCLUSIONS: DOAC-treated patients seem to have lower risk of posttraumatic intracranial bleeding compared with VKA-treated patients.

Effectiveness of Manchester Triage System in risk prioritisation of patients with pulmonary embolism who present dyspnoea, chest pain or collapse.

BACKGROUND: Recognising patients with pulmonary embolism continues to be a clinical challenge. In the Emergency Department, up to 50% of patients with pulmonary embolism can be delayed or even misdiagnosed. The ability of a triage system to correctly prioritise suspected embolism in these patients is fundamental for determining diagnostic-therapeutic procedures. AIM: To verify the effectiveness of the Manchester Triage System in risk prioritisation of patients with pulmonary embolism who present with dyspnoea, chest pain, or collapse. METHODS: In this observational, retrospective, study the sensitivity, specificity, and positive and negative predictive values of the Manchester Triage System were calculated using the triage classification for these patients, and their established diagnoses. The analysis included baseline characteristics and triage evaluations. RESULTS: During the two-year study period, 7055 patients were enrolled. Pulmonary embolism episodes were 2.1% of all cases, while severe pulmonary embolisms were 0.8%. The estimated specificity of the Manchester Triage System was 72.5% (CI 95%, 71.5-73.6), and the negative predictive value was 98.1% (CI 95%, 97.7-98.5). The results suggest that clinical characteristics leading to a high Manchester Triage System priority are similar to those characterising a pulmonary embolism episode. CONCLUSIONS: Although pulmonary embolism is difficult to diagnose, the Manchester Triage System is an effective tool for prioritising patients with symptoms of this disease.

Thirty-day mortality in atrial fibrillation patients with gastrointestinal bleeding in the emergency department: differences between direct oral anticoagulant and warfarin users.

More clinical data are required on the safety of direct oral anticoagulants (DOACs). Although patients treated with warfarin and DOACs have a similar risk of bleeding, short-term mortality after a gastrointestinal bleeding (GIB) episode in DOAC-treated patients has not been clarified. The objective of this study was to assess differences in 30-day mortality in patients treated with DOACs or warfarin admitted to the emergency department (ED) for GIB. This was a multicentre retrospective study conducted over 2 years. The study included patients evaluated at three different EDs for GIB. The baseline characteristics were included. Subsequently, we assessed the differences in past medical history and clinical data between the two study groups (DOAC and warfarin users). Differences between the two groups were evaluated using Kaplan-Meier curves. Among the 284 patients presenting GIB enrolled in the study period, 39.4% (112/284) were treated with DOACs and 60.6% (172/284) were treated with warfarin. Overall, 8.1% (23/284) of patients died within 30 days. Among the 172 warfarin-treated patients, 8.7% (15/172) died within 30 days from ED evaluation. In the 112 DOAC-treated patients, the mortality rate was 7.1% (8/112). The Cox regression analysis, adjusted for possible clinical confounders, and the Kaplan-Meier curves did not outline differences between the two treatment groups. The present study shows no differences between DOACs and warfarin in short-term mortality after GIB.

Evaluation of Neutrophil-lymphocyte and Platelet-lymphocyte Ratios as Predictors of 30-day Mortality in Patients Hospitalized for an Episode of Acute Decompensated Heart Failure.

BACKGROUND: To investigate the association between both neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) and 30-day mortality in patients hospitalized for an episode of acute decompensated heart failure (ADHF). METHODS: 439 patients admitted to emergency department (ED) for an episode of ADHF. Clinical history, demographic, clinical and laboratory data recorded at ED admission and then correlated with 30-day mortality. RESULTS: 45/439 (10.3%) patients died within 30 days from ED admission. The median values of NLR (4.1 vs 11.7) and PLR (159.1 vs 285.9) were significantly lower in survivors than in patients who died. The area under the ROC curve of NLR was significantly higher than that of the neutrophil count (0.76 vs 0.59; p<0.001), whilst the AUC of PLR was significantly better than that of the platelet count (0.71 vs 0.51; p<0.001). In univariate analysis, both NLR and PLR were significantly associated with 30-day. In the fully-adjusted multivariate model, NLR (odds ratio, 3.63) and PLR (odds ratio, 3.22) remained independently associated with 30-day mortality after ED admission. CONCLUSIONS: Routine assessment of NLR and PLR at ED admission may be a valuable aid to complement other conventional measures for assessing the medium-short risk of ADHF patients.

Red Blood Cell Distribution Width Improves Reclassification of Patients Admitted to the Emergency Department with Acute Decompensated Heart Failure.

BACKGROUND: The usual history of chronic heart failure (HF) is characterized by frequent episodes of acute decompensation (ADHF), needing urgent management in the emergency department (ED). Since the diagnostic accuracy of routine laboratory tests remains quite limited for predicting short-term mortality in ADHF, this retrospective study investigated the potential significance of combining red blood cell distribution width (RDW) with other conventional tests for prognosticating ADHF upon ED admission. METHODS: We conducted a retrospective study including visits for episodes of ADHF recorded in the ED of the Uni versity Hospital of Verona throughout a 4-year period. Demo - graphic and clinical features were recorded upon patient presentation. All patients were subjected to standard Chest X-ray, electrocardiogram (ECG) and laboratory testing in - cluding creatinine, blood urea nitrogen, B-type natriuretic peptide (BNP), complete blood cell count (CBC), sodium, chloride, potassium and RDW. The 30-day overall mortality after ED presentation was defined as primary endpoint. RESULTS: The values of sodium, creatinine, BNP and RDW were higher in patients who died than in those who survived, whilst hypochloremia was more frequent in patients who died than in those who survived. The multivariate model, incorporating these parameters, displayed a modest efficiency for predicting 30-day mortality after ED admission (AUC, 0.701; 95% CI, 0.662-0.738; p=0.001). Notably, the inclusion of RDW in the model significantly enhanced prediction efficiency, with an AUC of 0.723 (95% CI, 0.693-0.763; p<0.001). These results were confirmed with net reclassification improvement (NRI) analysis, showing that combination of RDW with conventional laboratory tests resulted in a much better prediction performance (net reclassification index, 0.222; p=0.001). CONCLUSIONS: The results of our study show that prognostic assessment of ADHF patients in the ED can be significantly improved by combining RDW with other conventional laboratory tests.

Early in-hospital variation of red blood cell distribution width predicts mortality in patients with acute heart failure.

BACKGROUND: Some studies showed that the value of red blood cell distribution width (RDW) at admission may predict clinical outcomes in patients with acutely decompensated heart failure (ADHF). Therefore, this study was planned to investigate whether in-hospital variations of RDW may also predict mortality in this condition. METHODS: The final study population consisted of 588 patients admitted to the local Emergency Department (ED), who were hospitalized for ADHF. The RDW was measured at ED admission and after 48h and 96h of hospital stay. In-hospital variations from admission value, expressed as absolute variation (DeltaRDW) or percent variation (Delta%RDW), were then correlated with 30- and 60-day mortality. RESULTS: Overall, 87 (14.8%) and 118 (20.1%) patients with ADHF died at 30 or 60days of follow-up. Delta%RDW after 96h of hospital stay independently predicted 30-day mortality (odds ratio, 1.12; 95% CI, 1.07-1.18). An increase >1% of Delta%RDW after 96h of hospital stay independently predicted both 30-day (odds ratio, 2.86; 95% CI, 1.67-4.97) and 60-day (odds ratio, 3.06; 95% CI, 1.89-4.96) mortality. A similar trend was observed for DeltaRDW, since an increase after 96h of hospital stay was associated with a nearly 4-fold higher 30-day mortality (odds ratio, 3.65; 95% CI, 2.02-6.15). CONCLUSION: Despite it remains unclear whether RDW is a real risk factor or an epiphenomenon in ADHF, these results suggest that more aggressive management may be advisable in ADHF patients with increasing anisocytosis during the first days of hospitalization.

The beneficial effect of biventricular pacing on ventricular tachycardia in a patient with non-ischemic cardiomyopathy.

The effect of cardiac resynchronisation therapy on ventricular tachycardias (VT) has not been well established. This case-report demonstrates the favourable impact of biventricular pacing on ventricular arrhythmias. In 2004, a patient with dilated cardiomyopathy and ICD since 1999 was admitted to our Division for multiple VT. While left ventricular function was markedly reduced and mitral regurgitation was severe, he was asymptomatic for heart failure. Amiodarone was not administered on account of a documented proarrhythmic effect. The patient's ICD was upgraded to an ICD-biventricular system. After upgrading, a significant reduction in the number of VT was noted.