Ambulatory Versus In-Hospital Treatment of Proximal Lower-Limb Deep Vein Thrombosis in Adults: A Retrospective Cohort Study

Background: Complications of deep vein thrombosis (DVT) are related to adequacy of initial anticoagulant therapy. In this study, we analyze consecutive patients with lower-limb proximal DVT and compare the characteristics, treatment, and clinical outcomes of patients receiving entirely ambulatory treatment versus those hospitalized for initial treatment. Methods: This was a retrospective study of consecutive patients with a first proximal lower-limb DVT during a 2-year period. Patients were followed for 90 days. Major end points were all-cause mortality, bleeding requiring hospitalization, and recurrent venous thromboembolism (VTE). Events were determined for patients who were hospitalized versus those treated on an entirely ambulatory basis. Results: A total of 236 patients were included in the study. Of these, 147 patients were hospitalized and 89 patients received ambulatory treatment. There were 20 fatalities—18 in-hospital and 2 in-ambulatory patients ( P = .008). By multivariable Cox regression analysis, the presence of active cancer (hazard ratio [HR] = 5.44; confidence interval [CI]: 2.16-13.7; P = .001), age (HR = 1.06; CI: 1.02-1.1; P = .001), and hospitalization (HR = 5.73; CI: 1.33-24.69; P = .019) were associated with death. Eight hospitalized and 2 ambulatory patients required readmission because of bleeding. Age was the only variable associated with bleeding (HR = 1.10; CI: 1.03-1.18; P = .004). There were no recurrent VTE events. Conclusion: In this study of routine management of proximal DVT, we demonstrate that patients suitable for ambulatory care are adequately identified by physicians and may be treated with equal safety and efficacy to hospitalized patients. </jats:sec

Stage-specific, Nonlinear Surface Ozone Damage to Rice Production in China

China is one of the most heavily polluted nations and is also the largest agricultural producer. There are relatively few studies measuring the effects of pollution on crop yields in China, and most are based on experiments or simulation methods. We use observational data to study the impact of increased air pollution (surface ozone) on rice yields in Southeast China. We examine nonlinearities in the relationship between rice yields and ozone concentrations and find that an additional day with a maximum ozone concentration greater than 120 ppb is associated with a yield loss of 1.12% ± 0.83% relative to a day with maximum ozone concentration less than 60 ppb. We find that increases in mean ozone concentrations, SUM60, and AOT40 during panicle formation are associated with statistically significant yield losses, whereas such increases before and after panicle formation are not. We conclude that heightened surface ozone levels will potentially lead to reductions in rice yields that are large enough to have implications for the global rice market

Bleeding in Patients with Atrial Fibrillation Treated with Different Doses of Direct Oral Anticoagulants and Vitamin K Antagonists: A Population-Based Study

Abstract INTRODUCTION Recent large randomized controlled trials have shown that direct oral anticoagulants (DOACs) are at least as effective as vitamin K antagonists (VKAs) for prevention of stroke or systemic embolism in patients with non-valvular atrial fibrillation (AF) and are associated with similar or lower rates of bleeding. The results for bleeding seen in Phase 3 trials might not be applicable to real world practice. Population-based studies suggest that the bleeding risk for DOACs and VKA is similar however neither the risk of bleeding associated with different doses of DOACs nor that associated with apixaban in routine clinical practice is well established. We performed a large population-based study to determine the incidence of bleeding in patients with AF beginning treatment with different doses of dabigatran, rivaroxaban, apixaban or a VKA. METHODS From the computerized database of the 4.5 million member Israeli Clalit Health Services health care provider, consecutive patients initiating a VKA or DOAC for AF between January 1, 2011 and December 31, 2014 were studied. Bleeding patients who required hospitalization were identified and key clinical and laboratory data were recorded. Incidence of bleeding was calculated during the first 20 months of treatment which was the minimum duration of treatment for all of the drugs. Adjusted hazard ratios for overall bleeding, intracranial hemorrhage (ICH) and gastrointestinal (GI) bleeding and all-cause mortality within 30 days were recorded and case fatality rates were calculated as the proportions of bleeding patients who died within 30 days. RESULTS 26184 patients initiated anticoagulants for AF: 14258 received VKA, 214 -received dabigatran 75 mg, 3563 received dabigatran 110 mg , 1410 received dabigatran 150 mg, 2570 received rivaroxaban 15 mg, 2140 received rivaroxaban 20 mg, 1227 received apixaban 2.5 mg and 802 received apixaban 5 mg. Key patient demographics and the overall and site-specific bleeding rates are shown in table 1. Hazard ratios for any bleeding, ICH and GI bleeding adjusted for age, renal failure, CHADS2 score, aspirin use and Charlson comorbidity score favored dabigatran 150 mg versus VKA (P&lt;0.05). The case fatality rate for VKA bleeding was 11,4%, dabigatran 110mg-10.5%, dabigatran 150 mg- 6.25%. rivaroxaban 15mg- 15.5%, rivaroxaban 20 mg- 10%, apixaban 2.5 mg- 11.4% and for apixaban 5mg-7.14% CONCLUSIONS The results of our population-based non-randomized study of unselected AF patients demonstrate a decreased bleeding rate for dabigatran 150mg and an increased bleeding rate for apixaban 2.5 mg compared to VKA. There was a consistent tendency for increased bleeding in patients receiving lower versus higher doses of the NOACs which probably reflects physician tendency to select lower doses of DOACs for patients at greater risk for bleeding. Disclosures Ellis: Boehringer Ingelheim: Speakers Bureau; Bayer: Speakers Bureau; Pfizer: Speakers Bureau. Eikelboom:Pfizer: Honoraria, Research Funding; Eli Lilly: Honoraria, Research Funding; Boehringer Ingelheim: Honoraria, Research Funding; Daiichi-Sankyo: Honoraria, Research Funding; Bayer: Honoraria, Research Funding; Astra Zeneca: Honoraria, Research Funding; Bristol Myer Squibb: Honoraria, Research Funding; Sanofi-Aventis: Honoraria, Research Funding; Janssen: Honoraria, Research Funding. </jats:sec

Impacts of biofuel cultivation on mortality and crop yields

Ground-level ozone is a priority air pollutant, causing ~ 22,000 excess deaths per year in Europe1, significant reductions in crop yields2 and loss of biodiversity3. It is produced in the troposphere through photochemical reactions involving oxides of nitrogen (NOx) and volatile organic compounds (VOCs). The biosphere is the main source of VOCs, with an estimated 1,150 TgC yr−1 (~ 90% of total VOC emissions) released from vegetation globally4. Isoprene (2-methyl-1,3-butadiene) is the most significant biogenic VOC in terms of mass (around 500 TgC yr−1) and chemical reactivity4 and plays an important role in the mediation of ground-level ozone concentrations5. Concerns about climate change and energy security are driving an aggressive expansion of bioenergy crop production and many of these plant species emit more isoprene than the traditional crops they are replacing. Here we quantify the increases in isoprene emission rates caused by cultivation of 72 Mha of biofuel crops in Europe. We then estimate the resultant changes in ground-level ozone concentrations and the impacts on human mortality and crop yields that these could cause. Our study highlights the need to consider more than simple carbon budgets when considering the cultivation of biofuel feedstock crops for greenhouse-gas mitigation