The Prognostic Performance of Rotational Thromboelastometry for Excessive Bleeding and Increased Transfusion Requirements in Hip Fracture Surgeries

2021 ◽  
Author(s):  
Andreas G. Tsantes ◽  
Dimitrios V. Papadopoulos ◽  
Ioannis G. Trikoupis ◽  
Konstantina A. Tsante ◽  
Andreas F. Mavrogenis ◽  
...  
Keyword(s):  
Hip Fracture ◽  
High Risk ◽  
Blood Loss ◽  
Bleeding Risk ◽  
Excessive Bleeding ◽  
Volume Number ◽  
Rotational Thromboelastometry ◽  
Prognostic Accuracy ◽  
Transfusion Requirements ◽  
Risk Patients

Abstract Background Hip fracture surgeries are associated with considerable blood loss, while the perioperative coagulopathy is associated with the bleeding risk of these patients. We aimed to evaluate the ability of rotational thromboelastometry (ROTEM) to detect patients at high risk for excessive bleeding and increased transfusion requirements. Methods We conducted a prospective observational study of 221 patients who underwent hip fracture surgeries. ROTEM analysis was performed preoperatively and immediately postoperatively. Blood loss parameters including blood loss volume, number of transfused red blood cell (RBC) units, and drop in hemoglobin levels were recorded. ROTEM parameters were compared between patients with and without excessive bleeding, and between patients with and without increased transfusion requirements (i.e., ≥2 RBC units). Results The postoperative FIBTEM MCF value ≤15 mm had 66.6% (95% confidence interval [CI]: 59.7–74.1%) sensitivity and 92.0% (95% CI: 80.7–97.7%) specificity to prognose excessive bleeding, and preoperative FIBTEM MCF value ≤15 mm had 80.4% (95% CI: 73.5–86.2%) sensitivity and 91.2% (95% CI: 80.7–97.0%) specificity to prognose increased transfusion requirements. Preoperative FIBTEM MCF ≤11 mm and postoperative FIBTEM MCF ≤15 mm were associated with considerably increased risks of excessive bleeding (odds ratio [OR]: 44.8, 95% CI: 16.5–121.3, p < 0.001; and OR: 23.0, 95% CI: 7.8–67.0, p < 0.001, respectively). Conclusion ROTEM parameters demonstrated high prognostic accuracy for excessive bleeding and increased transfusion requirements. This can enable implementation of blood sparing strategies in high-risk patients, while blood banks could be better prepared to ensure adequate blood supply.

scholarly journals Sex-based outcomes in contemporary antiplatelet therapy trials

Open Heart ◽  
2021 ◽  
Vol 8 (2) ◽  
pp. e001761
Author(s):  
Mirvat Alasnag ◽  
Tara L Jones ◽  
Yasmin Hanfi ◽  
Nicola Ryan
Keyword(s):  
High Risk ◽  
Antiplatelet Therapy ◽  
Bleeding Risk ◽  
Coronary Intervention ◽  
Representation Of Women ◽  
Percutaneous Coronary ◽  
Risk Patients ◽  
High Risk Populations ◽  
High Bleeding Risk ◽  
Randomised Controlled

Balancing ischaemic and bleeding risks in high-risk populations undergoing percutaneous coronary interventions has become an everyday dilemma for clinicians. It is particularly difficult to make decisions concerning combinations and duration of antiplatelet regimens in women given the poor representation of women in trials that have shaped current practice. Several contemporary landmark trials have recently been presented at the American College of Cardiology. The trials included the Harmonising Optimal Strategy for Treatment of coronary artery diseases-EXtended Antiplatelet Monotherapy, Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention and the TicAgrelor versus CLOpidogrel in Stabilised Patients With Acute Myocardial Infarction. In this article, we summarise the main findings of these trials and include the The Polymer-free Drug-Coated Coronary Stents in Patients at High Bleeding Risk (LEADERS FREE) in search for evidence based best practices for women patients. Although some of these trials had prespecified a subanalysis of sex differences, women constituted only 17%–30% of participants making sex-specific analyses challenging. Data suggest that women benefit from de-escalation to both ticagrelor and clopidogrel monotherapy. However, given the increased bleeding risks observed in women further randomised controlled trials are necessary to determine the most appropriate combination and duration of dual antiplatelet therapy as well as maintenance single antiplatelet therapy.

scholarly journals Use of a Combination of CEA and Tumor Budding to Identify High-risk Patients with Stage II Colon Cancer

2017 ◽  
Vol 32 (3) ◽  
pp. 267-273 ◽  
Author(s):  
Changzheng Du ◽  
Weicheng Xue ◽  
Fangyuan Dou ◽  
Yifan Peng ◽  
Yunfeng Yao ◽  
...  
Keyword(s):  
Colon Cancer ◽  
High Risk ◽  
Disease Progression ◽  
Disease Free Survival ◽  
Stage Ii ◽  
Tumor Budding ◽  
High Risk Patients ◽  
Prognostic Accuracy ◽  
Risk Patients ◽  
Stage Ii Colon Cancer

Background High-risk patients with stage II colon cancer may benefit from adjuvant chemotherapy, but identifying this patient population can be difficult. We assessed the prognosis value for predicting tumor progression in patients with stage II colon cancer, of a panel of 2 biomarkers for colon cancer: tumor budding and preoperative carcinoembryonic antigen (CEA). Methods Consecutive patients (N = 134) with stage II colon cancer who underwent curative surgery from 2000 to 2007 were included. Multivariate analysis was used to evaluate the association of CEA and tumor budding grade with 5-year disease-free survival (DFS). The prognostic accuracy of CEA, tumor budding grade and the combination of both (CEA-budding panel) was determined. Results The study found that both CEA and tumor budding grade were associated with 5-year DFS. The prognostic accuracy for disease progression was higher for the CEA-budding panel (82.1%) than either CEA (70.9%) or tumor budding grade (72.4%) alone. Conclusions The findings indicate that the combination of CEA levels and tumor budding grade has greater prognostic value for identifying patients with stage II colon cancer who are at high-risk for disease progression, than either marker alone.

P1558Clinical utility of the PRECISE-DAPT score in the prediction of hemorrhagic events in elderly patients with acute coronary syndrome

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
L Rioboo ◽  
E Abuassi Alnakeeb ◽  
S Raposeiras Roubin ◽  
I Munoz Pousa ◽  
M Cespon Fernandez ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
High Risk ◽  
Elderly Patients ◽  
Age Groups ◽  
Bleeding Event ◽  
Bleeding Risk ◽  
The Elderly ◽  
Coronary Syndrome ◽  
Risk Of Bleeding ◽  
Risk Patients

Abstract Introduction The clinical utility and validity of the PRECISE-DAPT bleeding risk score for elderly patients with acute coronary syndrome (ACS) is unknown. We investigated the previous aspect in a contemporary population treated with percutaneous coronary intervention (PCI) and dual antiplatelet therapy (DAPT) at discharge. Methods Retrospectively, from 2010 to 2016, we studied 3,814 consecutive patients with the diagnosis of ACS. All patients were treated with in-hospital PCI and DAPT at discharge. Elderly was defined if patients aged ≥75 years. Patients were categorized into three risk strata according to their PRECISE-DAPT score (very low-low: <17 points, moderate: 18–24 points, and high risk: ≥25 points). We included the first bleeding event occurred during the first year after discharge. Bleeding events were defined according to the BARC classification system, and divided into two subgroups: BARC 2–5 and BARC 3–5. The ability to separate high bleeding risk patients from lower bleeding risk patients was checked by the cumulative incidence function curves and compared using the Fine-Gray test, thus adjusting for death (non-bleeding related) as a competing risk. Discrimination (C statistic) and calibration (Hosmer-Lemeshow test) were used to test the predictive capacity of the score in pts aged ≥75 years and <75 years. Results 25.2% (n=961/3814) were ≥75 years old, 38.4% of them were women. DAPT duration was 11.5 (interquartile range [IQR] 2.5–13.7) vs. 12.0 (RIQ 8.2–14.1) months in the elderly vs. younger; (p<0.001). 92.5% (n=889) of the elderly were at high risk of bleeding (PRECISE-DAPT≥25 points), compared to 21.3% (n=607) of the youngest. The incidence of BARC 2–5 and BARC 3–5 was 7.4% and 2.7% in the elderly compared to 5.1% and 1.4% among the younger patients (p<0.001). The figure shows the ability of the PRECISE-DAPT score at capturing the risk of BARC 2–5 bleeding (panel A and B), in both age groups. Using the cut-off point ≥25, the effect in the prediction of BARC 2–5 bleeding and BARC 3–5 did not differ significantly between the elderly and those <75 years: sHR = 1.9 (95% CI: 1.2–6.00) in the elderly vs. 1.8 (95% CI: 1.3–2.5) in the other group (p=0.99) and sHR = 3.3 (95% CI: 1.9–6.0) vs. 3.6 (95% CI: 1.9–6.7) (p=0.83), respectively. There were no significant differences between the elderly and those under 75 years in terms of statistical C values either for BARC 2–5 bleeding (0.60 vs. 0.58) or BARC 3–5 bleeding (0.64 vs. 0.67). The score performed well in term of calibration in both groups (all p-values >0.3). Conclusion Although the use of PRECISE-DAPT resulted in classifying the majority of elderly patients at high risk of bleeding and despite exhibiting modest discriminative power, it performed well at classifying patients according to their risk of 1-year out-of-hospital bleeding in both age groups. PRECISE-DAPT appears to identify the truly low risk patients among the elderly, as compared to the younger group.

scholarly journals Can We Accurately Predict Which Geriatric and Middle-Aged Hip Fracture Patients Will Experience a Delay to Surgery?

2020 ◽  
Vol 11 ◽  
pp. 215145932094602
Author(s):  
Sanjit R. Konda ◽  
Joseph R. Johnson ◽  
Erin A. Kelly ◽  
Jeffrey Chan ◽  
Thomas Lyon ◽  
...  
Keyword(s):  
Hip Fracture ◽  
High Risk ◽  
Negative Binomial ◽  
Minimal Risk ◽  
Middle Aged ◽  
Moderate Risk ◽  
Time To Surgery ◽  
High Risk Patients ◽  
Risk Patients ◽  
Trauma Triage

Introduction: This study sought to investigate whether a validated trauma triage risk assessment tool can predict time to surgery and delay to surgery. Materials and Methods: Patients aged 55 and older who were admitted for operative repair or arthroplasty of a hip fracture over a 3-year period at a single academic institution were included. Risk quartiles were constructed using Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) calculations. Negative binomial and multivariable logistic regression were used to evaluate time to surgery and delay to surgery, respectively. Pairwise comparisons were performed to evaluate 30-day mortality rates and demonstrate the effectiveness of the STTGMA tool in triaging mortality risk. Results: Six hundred eleven patients met inclusion criteria with mean age 81.1 ± 10.5 years. Injuries occurred mainly secondary to low-energy mechanisms (97.9%). Median time to surgery (31.9 hours overall) was significantly associated with STTGMA stratification ( P = .002). Moderate-risk patients had 33% longer ( P = .019) and high-risk patients had 28% longer time to surgery ( P = .041) compared to minimal risk patients. Delay to surgery (26.4% overall) was significantly associated with STTGMA stratification ( P = .015). Low-risk patients had 2.14× higher odds ( P = .009), moderate-risk patients had 2.70× higher odds ( P = .001), and high-risk patients had 2.18× higher odds of delay to surgery ( P = .009) compared to minimal risk patients. High-risk patients experienced higher 30-day mortality compared to minimal ( P < .001), low ( P = .046), and moderate-risk patients ( P = .046). Discussion: Patients in higher STTGMA quartiles encountered longer time to surgery, greater operative delays, and higher 30-day mortality. Conclusion: Score for Trauma Triage in the Geriatric and Middle-Aged can quickly identify hip fracture patients at risk for a delay to surgery and may allow treatment teams to optimize surgical timing by proactively targeting these patients. Level of Evidence: Prognostic Level III.

scholarly journals The Role of Rapid Endoscopy for High-Risk Patients with Acute Nonvariceal Upper Gastrointestinal Bleeding

2007 ◽  
Vol 21 (7) ◽  
pp. 425-429 ◽  
Author(s):  
Laura E Targownik ◽  
Sanjay Murthy ◽  
Leila Keyvani ◽  
Shauna Leeson
Keyword(s):  
High Risk ◽  
Gastrointestinal Bleeding ◽  
Upper Gastrointestinal Bleeding ◽  
Tertiary Care ◽  
High Risk Patients ◽  
Transfusion Requirements ◽  
Significant Difference ◽  
Risk Patients ◽  
Upper Gastrointestinal

BACKGROUND: Performance of endoscopy within 24 h is recommended for patients with acute nonvariceal upper gastrointestinal bleeding (ANVUGIB). It is unknown whether performing endoscopy early within this 24 h window is beneficial for clinically high-risk patients.METHODS: A retrospective review was performed to identify patients presenting to two tertiary care centres with ANVUGIB and either systolic blood pressure lower than 100 mmHg or heart rate greater than 100 beats/min on presentation between 1999 and 2004. Patients receiving endoscopy within 6 h (rapid endoscopy [RE]) were compared with patients undergoing endoscopy between 6 h and 24 h (early endoscopy [EE]). The primary outcome measure was the development of any adverse bleeding outcome (rebleeding, surgery for control of bleeding, in-hospital mortality or readmission within 30 days for ANVUGIB).RESULTS: There were 169 patients who met the entry criteria (77 RE patients and 92 EE patients). There was no significant difference in the development of any adverse bleeding outcomes between RE and EE patients (25% RE versus 23% EE, difference between groups 2%, 95% CI −9% to 13%). Transfusion requirements and length of hospital stay also did not differ between the comparator groups. RE was not associated with fewer adverse outcomes, even after adjusting for confounders.CONCLUSION: For clinically high-risk ANVUGIB patients, performing endoscopy within 6 h of presentation is no more effective than performing endoscopy between 6 h and 24 h after presentation. The role of RE in high-risk ANVUGIB patients requires further delineation in a prospective fashion.

scholarly journals Operative and Oncological Outcomes Comparing Sentinel Node Mapping and Systematic Lymphadenectomy in Endometrial Cancer Staging: Meta-Analysis With Trial Sequential Analysis

2021 ◽  
Vol 10 ◽  
Author(s):  
Yu Gu ◽  
Hongyan Cheng ◽  
Liju Zong ◽  
Yujia Kong ◽  
Yang Xiang
Keyword(s):  
Endometrial Cancer ◽  
High Risk ◽  
Blood Loss ◽  
Sequential Analysis ◽  
Meta Analysis ◽  
Current Evidence ◽  
Trial Sequential Analysis ◽  
High Risk Patients ◽  
Oncological Outcomes ◽  
Risk Patients

ObjectiveTo evaluate the utility of sentinel lymph node mapping (SLN) in endometrial cancer (EC) patients in comparison with lymphadenectomy (LND).MethodsComprehensive search was performed in MEDLINE, EMBASE, CENTRAL, OVID, Web of science databases, and three clinical trials registration websites, from the database inception to September 2020. The primary outcomes covered operative outcomes, nodal assessment, and oncological outcomes. Software Revman 5.3 was used. Trial sequential analysis (TSA) and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) were performed.ResultsOverall, 5,820 EC patients from 15 studies were pooled in the meta-analysis: SLN group (N = 2,152, 37.0%), LND group (N = 3,668, 63.0%). In meta-analysis of blood loss, SLN offered advantage over LND in reducing operation bleeding (I2 = 74%, P&lt;0.01). Z-curve of blood loss crossed trial sequential monitoring boundaries though did not reach TSA sample size. There was no difference between SLN and LND in intra-operative complications (I2 = 7%, P = 0.12). SLN was superior to LND in detecting positive pelvic nodes (P-LN) (I2 = 36%, P&lt;0.001), even in high risk patients (I2 = 36%, P = 0.001). While no difference was observed in detection of positive para-aortic nodes (PA-LN) (I2 = 47%, P = 0.76), even in high risk patients (I2 = 62%, P = 0.34). Analysis showed no difference between two groups in the number of resected pelvic nodes (I2 = 99%, P = 0.26). SLN was not associated with a statistically significant overall survival (I2 = 79%, P = 0.94). There was no difference in progression-free survival between SLN and LND (I2 = 52%, P = 0.31). No difference was observed in recurrence. Based on the GRADE assessment, we considered the quality of current evidence to be moderate for P-LN biopsy, low for items like blood loss, PA-LN positive.ConclusionThe present meta-analysis underlines that SLN is capable of reducing blood loss during operation in regardless of surgical approach with firm evidence from TSA. SLN mapping is more targeted for less node dissection and more detection of positive lymph nodes even in high risk patients with conclusive evidence from TSA. Utility of SLN yields no survival detriment in EC patients.

scholarly journals Does Comanagement of Patients With Hip Fracture Influence 30-Day Outcomes

2020 ◽  
Vol 11 ◽  
pp. 215145932090199 ◽  
Author(s):  
Nirav K. Patel ◽  
Clifford Y. Ko ◽  
Xiangju Meng ◽  
Mark E. Cohen ◽  
Bruce L. Hall ◽  
...  
Keyword(s):  
Hip Fracture ◽  
High Risk ◽  
Hip Fractures ◽  
High Risk Group ◽  
Improvement Program ◽  
Surgical Quality ◽  
Orthopedic Surgeons ◽  
Orthogeriatric Comanagement ◽  
American College Of Surgeons ◽  
Risk Patients

Introduction: Comanagement of hip fractures is thought to optimize outcomes for these high-risk patients, but this practice is not universal. We aimed to determine whether comanagement of patients with hip fracture affects 30-day outcomes. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all hip fractures between January 2015 and January 2017, totaling 15 461 patients (144 hospitals). Patients were divided into 3 cohorts: 11 233 comanaged throughout stay (CM), 2537 partially comanaged during stay (PCM), or 1691 not comanaged (NCM), by orthopedic surgeons with medicine physicians or geriatricians. Data collected included demographics, hip fracture type, postoperative outcomes, and length of stay (LOS). Logistic regression and linear regression analyses were performed. Results: Both CM and PCM patients were older, with more dementia, poorer mobility, and more comorbidities than NCM patients. Mortality rates were 4.55%, 0.81%, and 0.33% for CM, PCM, and NCM, respectively, and risk-adjusted odds ratios (ORs) were 1.63 (95% confidence interval = 1.22-2.23) and 1.22 (0.87-1.74) for CM and PCM, respectively, compared to NCM. Morbidity rates were 11.06%, 15.45%, and 7.63% for CM, PCM, and NCM, respectively, and ORs were 1.74 (1.41-2.16) and 1.94 (1.57-2.41) for CM and PCM, respectively, compared to NCM. Risk-adjusted mean square LOS was 6.38, 8.80, and 7.23 for CM, PCM, and NC, respectively (P < .01). Conclusions: Comanaged patients with hip fracture had poorer cognition, function, and general health, with the shortest LOS. Surprisingly, NCM was associated with reduced morbidity and mortality, which may relate to them being the healthiest patients. Overall, our findings still support orthogeriatric comanagement in this high-risk group to maximize outcomes.

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