Right ventricle dysfunction (RVD) at echocardiography predicts mortality in patients with acute pulmonary embolism (PE), but heterogeneous definitions of RVD have been used. We performed a meta-analysis to assess the role of different definitions of RVD and of individual parameters of RVD as predictors of death.A systematic search for studies including patients with confirmed PE reporting on right ventricle (RV) assessment at echocardiography and death in the acute phase was performed. The primary study outcome was death in-hospital or at 30 days.RVD at echocardiography, regardless of its definition, was associated with increased risk of death (risk ratio 1.49, 95% CI 1.24-1.79, I2=64%) and PE-related death (risk ratio 3.77, 95% CI 1.61-8.80, I2=0%) in all-comers with PE, and with death in haemodynamically stable patients (risk ratio 1.52, 95% CI 1.15-2.00, I2=73%). The association with death was confirmed for RVD defined as the presence of at least one criterion or at least two criteria for RV overload. In all-comers with PE, increased RV/left ventricle (LV) ratio (risk ratio 1.61, 95% CI 1.90-2.39) and abnormal tricuspid annular plane systolic excursion (TAPSE) (risk ratio 2.29 CI 1.45-3.59) but not increased RV diameter were associated with death; in haemodynamically stable patients, neither RV/LV ratio (risk ratio 1.11, 95% CI 0.91-1.35) nor TAPSE (risk ratio 2.29, 95% CI 0.97-5.44) were significantly associated with death.Echocardiography showing RVD is a useful tool for risk stratification in all-comers with acute PE and in haemodynamically stable patients. The prognostic value of individual parameters of RVD in haemodynamically stable patients remains controversial.
Abstract It is well established that the risk of venous thromboembolism is high in coronavirus disease 19 (COVID-19). The frequency of arterial thromboembolic events (ATEs) in hospitalized patients with COVID-19 is unclear, as is the magnitude of these events in comparison with other infections. We searched MEDLINE from February 2020 to February 2022 for prospective or retrospective cohort studies and randomized clinical trials that reported the number of acute myocardial infarction (AMI), acute ischemic stroke (AIS), acute limb ischemia (ALI), or other ATE as defined by the original authors in hospitalized patients with COVID-19. The pooled frequencies were calculated through meta-analysis using random effects model with logit transformation and presented with relative 95% prediction intervals (95% PI). We retrieved a total of 4,547 studies, 36 of which (28 retrospective cohorts, five prospective cohorts and three randomized trials) were finally included in our analysis. The resulting cohort counted 100,949 patients, 2,641 (2.6%) of whom experienced ATE. The pooled ATE frequency was 2.0% (95% PI, 0.4–9.6%). The pooled ATE frequency for AMI, AIS, ALI, and other ATE was 0.8% (95% PI, 0.1–8.1%), 0.9% (95% PI, 0.3–2.9%), 0.2% (95% PI, 0.0–4.2%), and 0.5% (95% PI, 0.1–3.0%), respectively. In comparison with the ATE incidence reported in three studies on non-COVID viral pneumonia, we did not detect a significant difference from the results in our analysis. In conclusion, we found a non-negligible proportion of ATE in patients hospitalized for COVID-19. Our results are similar to those found in hospitalized patients with influenza or with non-COVID viral pneumonia.
Objective. Recently, the Italian Ministries of University and Health implemented a standardized accreditation system for post-graduate medical schools. Therefore, assessing the satisfaction and expectations of residents in the Geriatrics academic program may help identify the major critical issues to address. We conducted a survey to evaluate residents' satisfaction with theoretical, statistical and clinical training and to investigate their research attitude. Methods. A nationwide electronic survey was developed by the Young Epidemiologists group of the Italian Society of Gerontology and Geriatrics (YES) from December 2020 to February 2021 and disseminated among the Italian residents in Geriatrics attending the II-IV specialization year. The survey asked about the ongoing training activities in the theoretical, research, and clinical areas and the residents' satisfaction with them. Results. 210 eligible residents participated in the survey (47.5% from Northern, 26.9% Central, 23.6% Southern Italy). Thirty-five percent of participants attended > 10 lessons/year (more frequently in Northern Italy), and 52% took part in statistics lessons. Around one-third (32%) were satisfied with the duration and quality of the classes. Satisfaction with the educational offer was < 50% in every clinical area. Eighty percent of participants were interested in research, but only 47% participated in research activities. Conclusions. From the residents' point of view, the Italian geriatric medicine residency program may have wide improvement margins. The recent update of residency programs according to National standards might improve residents' satisfaction. Promoting education on research methodology through appropriate courses and ensuring dedicated time for research activities could increase residents' satisfaction and research quality.
Transthoracic echocardiography (TTE) is the standard technique for assessing aortic stenosis (AS), with effective orifice area (EOA) recommended for grading severity. EOA is operator-dependent, influenced by a number of pitfalls and requires multiple measurements introducing independent and random sources of error. We tested the diagnostic accuracy and precision of aliased orifice area planimetry (AOA
Background : Dexamethasone is part of the standard treatment of COVID-19 patients who need oxygen support. COVID-19 patients have a high risk of venous and arterial thrombosis, therefore adequate anticoagulation is of vital importance. Direct oral anticoagulants (DOACs) are generally not recommended in patients with dexamethasone due to possible drug-drug interactions which may decrease DOACs plasma levels. Therefore, data on the interaction between dexamethasone and DOACs is urgently needed. Aims : To assess DOAC plasma levels in patients with simoultaneous use of dexamethasone. Methods : Trough and peak DOAC plasma levels, by means of antiactivated factor X (anti-Xa) were prospectively collected in hospitalized COVID-19 patients treated with dexamethasone and DOACs (apixaban, rivaroxaban and edoxaban) and in hospitalized COVID-19 patients treated with DOACs only, to assess whether these values were within reference range. Results : Data were collected across two centres in Italy and the Netherlands. A total of 20 patients, 16 with DOACs and dexamethasone and 4 with DOACs only were enrolled. Twelve patients were on anticoagulant treatment for atrial fibrillation, seven for venous thromboembolism, and one for myocardial infarction. In 15 patients DOACs were started during the hospitalization. None of the patients had trough DOAC plasma levels below reference range. Only one patient (6.3%) treated with rivaroxaban had peak levels below reference range. Six patients (37.5%) in the dexamethasone group and two control patients (50%) had peak or trough DOAC plasma levels above reference range. Conclusions : In COVID-19 patients, the effect of dexamethasone use on DOAC plasma levels seems limited. This suggests that DOACs can be safely started or continued in COVID-19 patients treated with dexamethasone.
Abstract Aims Acute heart failure (AHF) represents a frequent cause of hospitalization and is associated with significant mortality among elderly patients. Risk assessment models like the prognostic nutritional index (PNI) have been proposed to stratify the risk of death and identify patients requiring more intensive levels of care. We evaluated the predictive value of PNI for in‐hospital and overall mortality in a cohort of consecutive elderly patients hospitalized for AHF. Methods and results Prognostic nutritional index, laboratory, and clinical parameters were collected upon admission. PNI values were calculated from albumin concentration and lymphocyte count and reported on a continuous scale with lower values indicating worse prognosis. The primary outcome was overall all‐cause mortality defined as death from any cause occurring during hospitalization up to 6 months after discharge. Cox proportional regression analysis was used to calculate hazard ratios (HRs) and the relative 95% confidence intervals (CIs). The study population included 344 patients (median age 84 years, range 65 to 101). During a median follow‐up of 158 days (range 2 to 180 days), 75 patients (21.8%) died of whom 28 (8.1%) died during hospitalization. The median PNI was 34 (range 17 to 55). In univariable analysis, PNI was inversely associated with overall mortality (HR 0.90; 95% CI, 0.87 to 0.94) and in‐hospital mortality (HR 0.91; 95% CI, 0.85 to 0.98). In multivariable analysis, PNI remained a significant predictor of overall mortality (HR 0.93; 95% CI, 0.89 to 0.98) after adjustment for age, anaemia, NT‐proBN P values, and bedridden status. PNI values ≤34 were associated with a two‐fold higher risk of overall mortality (HR 2.54; 95% CI, 1.52 to 4.24) and three‐fold higher risk of in‐hospital mortality (HR 3.37; 95% CI, 1.14 to 9.95). Conclusions Low PNI values are associated with short‐term and long‐term mortality among elderly patients hospitalized for acute decompensated heart failure. Future studies are warranted to confirm these findings and evaluate the use of PNI to guide therapeutic decisions.
