Background: Traditionally, patients with pulmonary embolism (PE) are initially treated in the hospital with low molecular weight heparin (LMWH). The results of a few small non‐randomized studies ...suggest that, in selected patients with proven PE, outpatient treatment is potentially feasible and safe. Objective: To evaluate the efficacy and safety of outpatient treatment according to predefined criteria in patients with acute PE. Patients and Methods: A prospective cohort study of patients with objectively proven acute PE was conducted in 12 hospitals in The Netherlands between 2008 and 2010. Patients with acute PE were triaged with the predefined criteria for eligibility for outpatient treatment, with LMWH (nadroparin) followed by vitamin K antagonists. All patients eligible for outpatient treatment were sent home either immediately or within 24 h after PE was objectively diagnosed. Outpatient treatment was evaluated with respect to recurrent venous thromboembolism (VTE), including PE or deep vein thrombosis (DVT), major hemorrhage and total mortality during 3 months of follow‐up. Results: Of 297 included patients, who all completed the follow‐up, six (2.0%; 95% confidence interval CI 0.8–4.3) had recurrent VTE (five PE 1.7% and one DVT 0.3%). Three patients (1.0%, 95% CI 0.2–2.9) died during the 3 months of follow‐up, none of fatal PE. Two patients had a major bleeding event, one of which was fatal intracranial bleeding (0.7%, 95% CI 0.08–2.4). Conclusion: Patients with PE selected for outpatient treatment with predefined criteria can be treated with anticoagulants on an outpatient basis. (Dutch Trial Register No 1319; http://www.trialregister.nl/trialreg/index.asp).
Summary
Background
There has been debate over how patients with pulmonary embolism (PE) can be safely selected for outpatient treatment.
Objectives
To compare the Hestia criteria with the European ...Society of Cardiology (ESC) criteria for selecting low‐risk patients with PE for outpatient treatment.
Methods
From 2008 to 2010, 496 patients with acute, symptomatic PE were screened and 275 treated at home and 221 treated in the hospital according to the Hestia Study protocol. The Hestia criteria were used to select patients for outpatient treatment. Right and left ventricular (RV and LV) diameters were measured on computed tomography images. RV dysfunction was defined as an RV/LV ratio > 1.0. Patients were classified according to the ESC criteria into low, intermediate and high‐risk groups, based on blood pressure and RV dysfunction. During 3 months follow‐up adverse events were scored.
Results
Adverse events occurred in 22 patients (4.5%) treated in the hospital vs. none of the patients treated at home (P < 0.001). Sensitivity and negative predictive value for adverse outcome were 100% for the Hestia criteria and 96% and 99% for the ESC criteria, respectively. Of the patients treated at home according to the Hestia criteria, 35% were normotensive but had RV dysfunction and were classified as intermediate risk according to the ESC criteria. No adverse events happened in these patients treated at home.
Conclusions
Clinical criteria, such as the Hestia criteria, could be helpful in selecting patients, including those with RV dysfunction who have a low risk of adverse clinical outcome and could be candidates for outpatient treatment.
The effects of the timing of insemination relative to ovulation on fertilization rate, accessory sperm count and early embryo development were studied in sows. Oestrus detection was performed at ...intervals of 8 h. Sows were artificially inseminated once with 3 x 10(9) spermatozoa. Transrectal ultrasonography was performed at intervals of 4 h to determine when ovulation occurred and sows were killed at 120 +/- 6 h after ovulation. For each insemination-ovulation interval of 8 h, fertilization rates were as follows: > 48 h, 35% (n = 1); 48-40 h, 51 +/- 36% (n = 6); 40-32 h, 54 +/- 36% (n = 14); 32-24 h, 79 +/- 32% (n = 19); 24-16 h, 94 +/- 11% (n = 24); 16-8 h, 92 +/- 21% (n = 24); 8-0 h, 95 +/- 22% (n = 21) and for the sows that were inseminated after ovulation: 0 to -8 h, 75 +/- 38% (n = 26); -8 to -16 h, 74 +/- 43% (n = 15) and < -16 h, 0% (n = 1). The median accessory sperm count differed among the groups from 1 (insemination 40-48 h before ovulation) to 126 (insemination 0-8 h after ovulation) (P = 0.0001). Within each 8 h time interval, the normal embryos from sows with less than 90% normal embryos were less developed and had a lower sperm count than did the normal embryos from sows with more than 90% normal embryos (P < 0.05).
Insemination immediately after ovulation causes low fertilization results owing to a low fertilization rate and possibly also owing to polyspermic fertilization. The present experiment was undertaken ...to study the effects of a second insemination after ovulation on fertilization rate and embryonic development. In multiparous crossbred sows, transrectal ultrasonography was used at intervals of 4 h to determine ovulation. All sows (n = 91) were artificially inseminated with 3 x 10(9) mixed spermatozoa and, in 31 sows, a second insemination took place at 3 +/- 1 (mean +/- SD) h after ovulation. At 119 +/- 5 h after ovulation, the percentage of normal embryos and the accessory sperm count were determined. In the sows that were inseminated once, the percentage of normal embryos decreased when insemination took place more than 24 h before ovulation, from 88 +/- 20% (16-24 h; n = 15) to 63 +/- 40% (24-32 h; n = 10) (P < 0.05). In the sows that were inseminated again after ovulation, the percentage of normal embryos was high, irrespective of the period between first insemination and ovulation. The difference in percentage of normal embryos between the sows that were inseminated once or twice was significant when the first insemination took place between 24 and 32 h before ovulation; 63 +/- 40% (inseminated once, n = 10) and 97 +/- 5% (inseminated twice, n = 8) (P < 0.05). The accessory sperm count of the normal embryos in a litter was positively related to the percentage of normal embryos in a litter, and this relation was not affected by the interval between first insemination and ovulation or by the number of inseminations.
•Attempts have been made to stabilize calcium chloride-based materials.•Impregnation and microencapsulation methods are applied.•Stability, kinetics and energy density are investigated.•Combined ...TGA-DSC methods and microscopic observation are employed.•Microencapsulation improved stability and kinetics but not energy density.
Thermochemical heat storage in salt hydrates is a promising method to improve the solar fraction in the built environment. The major concern at this stage is liquefaction followed by washing out of active material and agglomeration into large chunks of salt, thus deteriorating the diffusive properties of the porous salt hydrate structure. In this work, specific attention is given to the methods to stabilize a sample salt hydrate. Attempts have been made to stabilize calcium chloride by impregnation in expanded natural graphite and vermiculite, and by microencapsulation with ethyl cellulose. The effect of these stabilization methods on the performance of the material, such as kinetics and energy density, is investigated. Characterization of the materials is carried out with combined Thermo-Gravitational Analysis (TGA) and Differential Scanning Calorimetry (DSC) methods and microscopic observation, in order to evaluate the improvements on the basis of three subjects: reaction kinetics, heat storage density and stability. Within the boundary conditions for thermochemical energy storage as presented in this work, microencapsulated calcium chloride showed high multicyclic stability, compared with pure and impregnated materials, that liquefy upon hydration under the given conditions. Microencapsulated material remains stable over multiple cycles and at the same time shows the faster kinetics, but has a lower volumetric energy storage density.
The Utrecht Cardiovascular Cohort - CardioVascular Risk Management (UCC-CVRM) was set up as a learning healthcare system (LHS), aiming at guideline based cardiovascular risk factor measurement in all ...patients in routine clinical care. However, not all patients provided informed consent, which may lead to participation bias. We aimed to study participation bias in a LHS by assessing differences in and completeness of cardiovascular risk management (CVRM) indicators in electronic health records (EHRs) of consenting, non-consenting, and non-responding patients, using the UCC-CVRM as an example.
All patients visiting the University Medical Center Utrecht for first time evaluation of a(n) (a)symptomatic vascular disease or condition were invited to participate. Routine care data was collected in the EHR and an informed consent was asked. Differences in patient characteristics were compared between consent groups. We performed multivariable logistic regression to identify determinants of non-consent. We used multinomial regression for an exploratory analysis for the determinants of non-response. Presence of CVRM indicators were compared between consent groups. A waiver (19/641) was obtained from our ethics committee.
Out of 5730 patients invited, 2378 were consenting, 1907 non-consenting, and 1445 non-responding. Non-consent was related to young and old age, lower education level, lower BMI, physical activity and haemoglobin levels, higher heartrate, cardiovascular disease history and absence of proteinuria. Non-response increased with young and old age, higher education level, physical activity, HbA1c and decreased with lower levels of haemoglobin, BMI, and systolic blood pressure. Presence of CVRM indicators was 5-30% lower in non-consenting patients and even lower in non-responding patients, compared to consenting patients. Non-consent and non-response varied across specialisms.
A traditional informed consent procedure in a LHS may lead to participation bias and potentially to suboptimal CVRM, which is detrimental for feedback on findings in a LHS. This underlines the importance of reassessing the informed consent procedure in a LHS.
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