The measurement of D-dimer can provide useful information to aid in the diagnosis of patients with suspected venous thromboembolism. D-dimer measurement in conjunction with adequate estimation of ...pretest probability can facilitate the safe discharge of patients with suspected pulmonary embolism and limit unnecessary investigation or anticoagulation. We review clinical decision-making strategies in the diagnosis of pulmonary embolism and propose means to minimize diagnostic error that might arise from knowledge of the D-dimer result prior to clinical assessment.
Aortic arch geometry changes with age, including an increase in aortic arch width (AAW). High AAW is a predictor of incident adverse cardiovascular disease (CVD) events, but its distribution and ...determinants are unknown. We hypothesized that traditional CVD risk factors, in addition to age, are associated with increased AAW in community-dwelling adults.
Framingham Offspring and Third Generation cohort participants (N = 3026, 52 % men) underwent thoracic multidetector computed tomography (MDCT). A referent group (733M, 738W) free of clinical CVD, hypertension, dyslipidemia, smoking, and diabetes was used to generate sex and 10-year age-group specific upper 90th percentile (P90) cut-points for AAW. AAW was measured as the distance between the cross-sectional centroids of the ascending and descending thoracic aorta. Multivariable logistic regression models were used to identify clinical correlates of high AAW (≥referent P90) in the overall study group.
Among referent participants, AAW increased with greater age-group, p for trend <0.0001 in each sex. Overall and within each age group, AAW was greater in men than women, p < 0.0001 all comparisons. Across all participants, high AAW was associated with greater age (odds ratio, OR = 1.34/10 years; 95 % confidence interval 1.20–1.50), body surface area (OR = 1.97/SD; 1.62–2.40), diastolic blood pressure (OR = 1.59/10 mm Hg; 1.40–1.81), pack-years smoked (OR = 1.07; 1.02–1.13), and prevalent CVD (OR = 1.64; 1.08–2.49).
AAW increases with greater age, body size, diastolic blood pressure and burden of smoking. High AAW (≥referent P90) is also associated with prevalent (clinically apparent) CVD. AAW is often seen on and easily measured from tomographic thoracic images and has prognostic value.
Many of the adverse outcomes experienced by mothers and babies are directly related to the health of the woman prior to pregnancy. This preconception period is a unique window of opportunity when ...women are often more motivated to optimise health and change their lifestyle in preparation for pregnancy. Several risk factors in the preconception period can contribute to adverse perinatal outcomes. These risk factors can be divided into three broad areas: biomedical, social and environmental. Mobile phone applications as a behaviour change intervention have the potential to address these risks through supporting the provision of information, healthier lifestyles and informed decision-making. The aim of this systematic review is to assess the effectiveness of mobile phone applications in promoting behaviour change and improving long-term outcomes for mother and babies, in women of reproductive age.
This review will include trials that assess any mobile phone application (app) that assist women of reproductive age to optimise health behaviours. Randomised controlled trials, quasi-randomised controlled trials and cluster-randomised trials will be included. The search strategy will use both MeSH and keyword combinations to search databases including the WHO Global Health Library, CINHAL, The Cochrane Library, Embase and MEDLINE for relevant studies. Retrieved citations will be screened independently by two authors to assess eligibility. Studies will be selected only if the intervention was commenced prior to pregnancy. Comparisons will be made including mobile phone applications versus text messaging-based communications or paper-based, face-to-face or telephone conversations and standard care or no specific intervention. The Cochrane Handbook for Systematic Reviews of Interventions will be utilised to assess the quality of included randomised studies. Primary and secondary outcomes will be compared and analysed. Results of the review will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) guidelines.
This systematic review is the first to assess the effects of preconception mobile phone app behaviour change and educational interventions in improving future pregnancy and maternal and child outcomes, in women of reproductive age.
PROSPERO 2017: CRD42017065903 .
We sought to determine whether increased aortic arch width (AAW) adds to standard Framingham risk factors and coronary artery calcium (CAC) for prediction of incident adverse cardiovascular disease ...(CVD) events in community-dwelling adults.
A total of 3026 Framingham Heart Study Offspring and Third Generation cohort participants underwent noncontrast multidetector computed tomography from 2002 to 2005 to quantify CAC. We measured AAW as the distance between the centroids of the ascending and descending thoracic aorta, at the level of main pulmonary artery bifurcation or the right pulmonary artery. We determined sex, age group, and body size specific cut points for high (≥90th percentile) AAW from a healthy referent group (N=1471) and dichotomized AAW as high or not high across all study participants. Clinical covariates were obtained at Offspring cycle 7 (1998-2001) or Third Generation cycle 1 (2002-2005) examinations. The primary CVD outcome was a composite of myocardial infarction, coronary insufficiency, cerebrovascular accident, first hospitalization for heart failure, or CVD death. Cox proportional hazards models were used to estimate hazard ratio of high AAW on time-to-incident CVD after adjustment for Framingham risk factors and CAC. Net reclassification improvement was used to assess the effect of adding AAW to the baseline Framingham risk factor+CAC model. A total of 2826 participants (aged 51±11 years, 48% women) had complete covariates and were free of CVD at multidetector computed tomography. Over a median 8.9 years of follow-up, there were 135 incident CVD events. High AAW was independently predictive of CVD events (hazard ratio, 1.55;
=0.032) and appropriately reclassified participants at risk: net reclassification improvement, 0.31 (95% confidence interval, 0.15-0.48).
AAW augments traditional CVD risk factors and CAC for prediction of incident adverse CVD events among community-dwelling adults.
A combined experimental and computational study of the reactivities of seven commonly used Michael acceptors paired with two thiols within the framework of photobase-catalyzed thiol-Michael reactions ...is reported. The rate coefficients of the propagation (
k
P
), reverse propagation (
k
-P
), chain-transfer (
k
CT
), and overall reaction (
k
overall
) were experimentally determined and compared with the well-accepted electrophilicity parameters of Mayr and Parr, and DFT-calculated energetics. Both Mayr's and Parr's electrophilicity parameters predict the reactivities of these structurally varying vinyl functional groups well, covering a range of overall reaction rate coefficients from 0.5 to 6.2 s
−1
. To gain insight into the individual steps, the relative energies have been calculated using DFT for each of the stationary points along this step-growth reaction between ethanethiol and the seven alkenes. The free energies of the individual steps reveal the underlying factors that control the reaction barriers for propagation and chain transfer. Both the propagation and chain transfer steps are under kinetic control. These results serve as a useful guide for Michael acceptor selection to design and predict thiol-Michael-based materials with appropriate kinetic and material properties.
A systematic investigation extends the fundamental understanding of the structure-property relationships between vinyl functionality and the reaction kinetics for the thiol-Michael reactions.
Epoxy-based polymer networks from step-growth polymerizations are ubiquitous in coatings, adhesives, and as matrices in composite materials. Dynamic covalent bonds in the network allow its ...degradation into small molecules and thus, enable chemical recycling; however, such degradation often requires elevated temperatures and costly chemicals, resulting in various small molecules. Here, we design crosslinked polyesters from structurally similar epoxy and anhydride monomers derived from phthalic acid. We achieve selective degradation of the polyesters through transesterification reactions at near-ambient conditions using an alkali carbonate catalyst, resulting in a singular phthalic ester. We also demonstrate upcycling the network polyesters to photopolymers by one-step depolymerization using a functional alcohol.
Recyclable network polymer is a key component of circular economy of materials. Here we demonstrate that recyclability is enhanced by introducing structural similarity in the molecular design of monomers.
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•Cancer-associated thrombosis (CAT) is a leading cause of death in cancer patients.•Introduction of direct oral anticoagulants has made treatment decisions complex.•An expert working ...group of clinicians met virtually to define consensus guidelines.•A practical colour-coded algorithm was produced to guide complex clinical decisions.
Cancer-associated thrombosis (CAT) is a leading cause of death amongst people with cancer. Treatment decisions have become increasingly complex with the introduction of direct oral anticoagulants and existing guidelines are limited to evidence from patients meeting stringent trial-entry criteria.
To assist decision making for healthcare professionals managing CAT in challenging ‘real-world’ situations, an expert working group of clinicians from oncology, haematology and pharmacology convened over a series of virtual meetings between September 2020 and January 2021 to catalogue the most challenging clinical problems and define consensus recommendations. Clinical problems were divided amongst the group members according to their areas of expertise, with each reviewing the literature and writing their recommendations. Using a web-based file-sharing platform, each contribution was reviewed until consensus was reached.
Each clinical problem is discussed; these include managing gastrointestinal impairment, renal impairment, liver impairment, increased risk of bleeding, extremes of body weight, drug interactions, anticoagulation beyond the initial six months and managing recurrent thrombosis.
A user-friendly, practical, colour-coded algorithm was produced to help guide clinical decision-making in CAT. Red highlights decision steps where shared decision making, such as with the multi-disciplinary team, is recommended. Amber steps reflect uncertainty of existing evidence. Multiple amber steps per patient warrant increased caution.
Making anticoagulation decisions in people with cancer is challenging; it is important that healthcare providers can discuss where there is a lack of evidence and ensure that patient preference is given priority. This algorithm and consensus recommendations are a useful tool to guide these complex discussions.
There is limited guidance available to clinicians regarding the management of antithrombotic therapy during epistaxis, whilst there has been an increase in the use of anticoagulation and antiplatelet ...therapy. In addition, the introduction of direct oral anticoagulants (DOACs), such as dabigatran and rivaroxaban, over the last decade has significantly increased the complexity of managing the anticoagulated epistaxis patient. We undertook a systemic literature review investigating potential management strategies for each class of anti-thrombotic therapy during epistaxis. A PubMED and Cochrane Library search was performed on 10/03/16 using, but not limited to, the search terms epistaxis, nosebleed, nose bleeding, nasal haemorrhage, nasal bleeding AND each of the following search terms: antithrombotic, anticoagulant, antiplatelet, aspirin, clopidogrel, warfarin, dabigatran, rivaroxaban, apixaban and tranexamic acid. This yielded 3815 results, of which 29 were considered relevant. Other sources such as national and international guidelines related to the management of anti-thrombotics were also utilised. We present the findings related to the management of each class of anti-thrombotic therapy during epistaxis. Overall we found a lack of evidence regarding this topic and further high quality research is needed. This is an area growing in complexity and the support of colleagues in Haematology and Cardiology is increasingly important.
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