[THE MANAGEMENT OF VENOUS THROMBOEMBOLISM IN A TERTIARY HOSPITAL - THE PRE DIRECT ORAL ANTICOAGULANTS (DOACS) ERA].

BACKGROUND: The use of direct oral anticoagulants (DOACs) provides immediate and useful anticoagulation without the need of monitoring. The recent expansion in use of DOACs might change the therapeutic approaches in venous thromboembolism (VTE). OBJECTIVES: To evaluate the treatment of VTE as well as the 90-days compliance with anticoagulants in the pre-DOACs era. METHODS: A retrospective study was conducted at Beilinson Hospital, Rabin Medical Center. Inclusion criteria entailed: patients >18 years old; new lower extremities deep vein thrombosis or pulmonary embolism, diagnosed at ER between May, 2014 and May, 2015. Patients with previous diagnosis; upper extremities or inner organs thrombosis or with missing data were excluded. Data collected included: gender and age, comorbidity with active malignancy, provoked/unprovoked events, hospitalization and length of stay, anticoagulation treatment during hospitalization and discharge, recommendations for duration of treatment or further hematologist's evaluation and 90-days compliance with anticoagulation treatment. RESULTS: The study group included 208 patients, 29% with active malignancy. All were hospitalized. In 54% of the subjects without active malignancy the event was provoked, whereas in 46% unprovoked. This detail was not discussed in any of the cases. The average length of stay tended to be longer in patients with a complete switch to warfarin than in ones on DOACs (10.3+7.5 vs. 6.4+5.2 days, p=0.09). Recommendations for the length of treatment or the need for further evaluation by a hematologist were not found in the majority. The overall 90-days compliance with anticoagulants was 47%. CONCLUSIONS: Most of the therapeutic approach errors might be resolved during the expanded use of DOACs, along with the simplicity of the recommendations at discharge. The study was supported by an educational grant from Pfizer, Inc.

The effect of indirect calorimetry guided isocaloric nutrition on mortality in critically ill patients-a systematic review and meta-analysis.

Indirect calorimetry (IC)-guided nutrition might positively affect the clinical outcome of critically ill patients. In this systematic review and meta-analysis, our objective was to assess the benefit of isocaloric nutrition guided by IC, compared to hypocaloric nutrition, for critically ill patients admitted to the intensive care unit (ICU). We performed a systematic review of all randomized controlled trials published through January 2021, assessing the benefit of isocaloric nutrition guided by IC. The primary outcome was 28-day all-cause mortality. Secondary outcomes were ICU and 90-day all-cause mortality, rate of nosocomial infections, and adverse events. Four trials evaluating 1052 patients were included. Patients treated with isocaloric nutrition had a lower 28-day mortality rate (risk ratio (RR) 0.79, 95% confidence interval (CI) 0.63-0.99, P = 0.04). No between-group difference was found in ICU and 90-day mortality (RR 0.92, 95% CI 0.68-1.23, P = 0.56 and RR 0.88, 95% CI 0.72-1.07; P = 0.2, respectively) and in the rate of nosocomial infections (RR 1.15, 95% CI 0.77-1.72, P = 0.51). A pooled analysis of studies that evaluated the benefit of isocaloric nutrition guided by IC, for critically ill patients in the ICU, has shown reduced 28-day mortality. However, there was no difference in 90-day mortality and nosocomial infection rate.

Quick cell-free DNA testing for the prediction of postconcussion syndrome: a single-center prospective pilot trial.

OBJECTIVE: Mild traumatic brain injury (mTBI) is a major cause of emergency room (ER) admission. Thirty percent of mTBI patients have postconcussion syndrome (PCS), and 15% have symptoms for over a year. This population is underdiagnosed and does not receive appropriate care. The authors proposed a fast and inexpensive fluorometric measurement of circulating cell-free DNA (cfDNA) as a biomarker for PCS. cfDNA is a proven, useful marker of a variety of acute pathological conditions such as trauma and acute illness. METHODS: Thirty mTBI patients were recruited for this prospective single-center trial. At admission, patients completed questionnaires and blood was drawn to obtain cfDNA. At 3-4 months after injury, 18 patients returned for cognitive assessments with questionnaires and the Color Trails Test (CTT). The fast SYBR Gold assay was used to measure cfDNA. RESULTS: Seventeen men and 13 women participated in this trial. The mean ± SD age was 50.9 ± 13.9 years. Of the 18 patients who returned for cognitive assessment, one-third reported working fewer hours, 4 (22.2%) changed their driving patterns, and 5 (27.7%) reduced or stopped performing physical activity. The median cfDNA level of the mTBI group was greater than that of the matched healthy control group (730.5 vs 521.5 ng/ml, p = 0.0395). Admission cfDNA concentration was negatively correlated with performance on the CTT1 and CTT2 standardized tests (r = -0.559 and -0.599), meaning that greater cfDNA level was correlated with decreased cognitive performance status. The performance of the patients with normal cfDNA level included in the mTBI group was similar to that of the healthy participants. In contrast, the increased cfDNA group (> 800 ng/ml) had lower scores on the CTT tests than the normal cfDNA group (p < 0.001). Furthermore, patients with moderate/severe cognitive impairment according to CTT1 results had a greater median cfDNA level than the patients with scores indicating mild impairment or normal function (1186 vs 473.5 ng/ml, p = 0.0441, area under the receiver operating characteristic curve = 0.8393). CONCLUSIONS: The data from this pilot study show the potential to use cfDNA, as measured with a fast test, as a biomarker to screen for PCS in the ER. A large-scale study is required to establish the value of cfDNA as an early predictor of PCS.