Intraossale infusie

ABSTRACT Intraosseous (IO) infusion is a long existing method to obtain vascular access and has gained renewed interest over the last decade. IO infusion is an easy, safe, rapid and effective alternative method for vascular access in emergency clinical care and prehospital situations. The IO access can be used for administration of fluids, medication, analysis of electrolytes, blood type and blood gasses. The proximal tibia is the most common insertion location. New IO needles (F.A.S.T.1., Bone Injection-Gun and EZ-IO) have been developed over the last decade, to make insertion easier. Guidelines such as the ATLS and ERC are changing and currently recommend the use of IO needles in the emergency setting, in trauma and non-trauma situations, in both children and adults as alternative for peripheral vascular access. This will increase the use of the IO needles in de future. Awareness of indications, contra-indications and complications should therefore be enhanced

Pairs, sets and sequences in first-order theories

Asuransi sebagai aktivitas bisnis diharuskan memenuhi prinsip-prinsip hukum asuransi. Salah satu prinsip yang harus dipegang teguh adalah principle of  utmost good faith, di samping prinsip yang lain. Prinsip ini berbunyi bahwa seorang tertanggung wajib memberi informasi secara jujur terhadap apa yang dipertanggungkan kepada penanggung. Dalam bisnis Islam, kejujuran merupakan prinsip yang harus dijunjung tinggi. Secara hukum, prinsip ini diatur dalam KUH Dagang. Persoalannya adalah apakah prinsip ini dianggap cukup dari sudut pandang hukum perjanjian syariah. Secara sekilas bahwa prinsip iktikad baik sempurna ini telah memenuhi asas perjanjian syariah, namun demikian tidak memiliki kriteria maksimal kejujuran. Ketiadaan kejujuran dalam bisnis asuransi akan berdampak pada batalnya perjanjian asuransi karena ada unsur cacat kehendak (‘uyub ar-ridla). Insurance as a business activity must fulfill principles of insurance law. One of the principles that must be hold on is the principle of  utmost good faith. The principle says that an endured person must honestly give information of  what should be given responsibility to the guarantor. In Islamic business, honesty is a principle that should be respected. From point of  view of  law, the principle is settled in commerce law. The problem is that whether the principle is represenative enough if it is viewed from law of  syariah agreement. At glance, the principle has fulfilled the basic of syariah agreement, however, it does not have maximum criteria of  honesty. Unavailability of honesty in insurance business will give effect of  invalidate of  insurance agreement, for there is a deformity of desire (‘uyub ar-ridla).</p

Proton pump inhibitors and gastroenteritis

An association between proton pump inhibitor (PPI) therapy and bacterial gastroenteritis has been suggested as well as contradicted. The aim of this study was to examine the association between the use of PPIs and occurrence of bacterial gastroenteritis in the prospective Rotterdam Study. The Rotterdam Study is a population-based cohort study among 14,926 subjects aged 45 years and older with up to 24 years of follow-up. Analyses were performed with a generalized estimating equations method in participants who handed-in a diagnostic stool sample. Furthermore, a nested case–control analysis was performed using the total cohort as a reference group. A bacterial microorganism was isolated in 125 samples, whereas 1174 samples were culture negative. In the generalized estimating equations analysis, we found that participants with a bacterial gastroenteritis were more likely than controls to be current users of PPIs (adjusted OR 1.94; 95 % CI 1.15–3.25). Different sensitivity analyses did not change this result. A considerably higher effect was observed (adjusted OR 6.14; 95 % CI 3.81–9.91), using the total cohort as a reference in a nested case–control analysis. Current PPI therapy is associated with an increased risk of bacterial gastroenteritis. However, by reducing the risk of selection and information bias in our study design, we demonstrated that the effect is lower than previously assumed

The risk of overanticoagulation in patients with heart failure on coumarin anticoagulants

Heart failure has been identified as a risk factor for increased coumarin anticoagulant responsiveness in several small-scale experiments. Epidemiological studies quantifying the risk of overanticoagulation by heart failure in a non-selected population on coumarins are scarce. Therefore, we investigated whether patients with heart failure have an increased risk of overanticoagulation and determined the effect of incidental heart failure on coumarin dose requirements. A cohort study of all patients was performed from an outpatient anticoagulation clinic treated with acenocoumarol or phenprocoumon between 1 January 1990 and 1 January 2000. All cohort members were followed until the first occurrence of an international normalized ratio (INR) ≥6.0, the last INR assessment, death, loss to follow-up, or end of the study period. Of the 1077 patients in the cohort, 396 developed an INR ≥6.0. The risk of overanticoag

Subclinical hypothyroidism is an independent risk factor for atherosclerosis and myocardial infarction in elderly women: the Rotterdam Study

BACKGROUND: Overt hypothyroidism has been found to be associated with cardiovascular disease. Whether subclinical hypothyroidism and thyroid autoimmunity are also risk factors for cardiovascular disease is controversial. OBJECTIVE: To investigate whether subclinical hypothyroidism and thyroid autoimmunity are associated with aortic atherosclerosis and myocardial infarction in postmenopausal women. DESIGN: Population-based cross-sectional study. SETTING: A district of Rotterdam, The Netherlands. PARTICIPANTS: Random sample of 1149 women (mean age +/- SD, 69.0 +/- 7.5 years) participating in the Rotterdam Study. MEASUREMENTS: Data on thyroid status, aortic atherosclerosis, and history of myocardial infarction were obtained at baseline. Subclinical hypothyroidism was defined as an elevated thyroid-stimulating hormone level (>4.0 mU/L) and a normal serum free thyroxine level (11 to 25 pmol/L [0.9 to 1.9 ng/dL]). In tests for antibodies to thyroid peroxidase, a serum level greater than 10 IU/mL was considered a positive result. RESULTS: Subclinical hypothyroidism was present in 10.8% of participants and was associated with a greater age-adjusted prevalence of aortic atherosclerosis (odds ratio, 1.7 [95% CI, 1.1 to 2.6]) and myocardial infarction (odds ratio, 2.3 [CI, 1.3 to 4.0]). Additional adjustment for body mass index, total and high-density lipoprotein cholesterol level, blood pressure, and smoking status, as well as exclusion of women who took beta-blockers, did not affect these estimates. Associations were slightly stronger in women who had subclinical hypothyroidism and antibodies to thyroid peroxidase (odds ratio for aortic atherosclerosis, 1.9 [CI, 1.1 to 3.6]; odds ratio for myocardial infarction, 3.1 [CI, 1.5 to 6.3]). No association was found between thyroid autoimmunity itself an

First attempt success of video versus direct laryngoscopy for endotracheal intubation by ambulance nurses: a prospective observational study

Purpose: The aim of this study was to compare the rate of first attempt success of endotracheal intubation performed by ambulance nurses in patients with a Glasgow Coma Scale (GCS) of 3 using video laryngoscopy versus direct laryngoscopy. Methods: A prospective cohort study was conducted in a single, independent ambulance service. Twenty of a total of 65 nurse-staffed ambulances were equipped with a video laryngoscope; a classic direct laryngoscope (Macintosh) was available on all 65 ambulances. The primary outcome was first attempt success of the intubation. Secondary outcomes were overall success, time needed for intubation, adverse events, technical or environmental issues encountered, and return of spontaneous circulation (ROSC). Ambulance nurses were asked if the intubation device had affected the outcome of the intubation. Results: The first attempt success rate in the video laryngoscopy group [53 of 93 attempts (

Fixed-point elimination in the intuitionistic propositional calculus

It is a consequence of existing literature that least and greatest fixed-points of monotone polynomials on Heyting algebras-that is, the algebraic models of the Intuitionistic Propositional Calculus-always exist, even when these algebras are not complete as lattices. The reason is that these extremal fixed-points are definable by formulas of the IPC. Consequently, the $\mu$-calculus based on intuitionistic logic is trivial, every $\mu$-formula being equivalent to a fixed-point free formula. We give in this paper an axiomatization of least and greatest fixed-points of formulas, and an algorithm to compute a fixed-point free formula equivalent to a given $\mu$-formula. The axiomatization of the greatest fixed-point is simple. The axiomatization of the least fixed-point is more complex, in particular every monotone formula converges to its least fixed-point by Kleene's iteration in a finite number of steps, but there is no uniform upper bound on the number of iterations. We extract, out of the algorithm, upper bounds for such n, depending on the size of the formula. For some formulas, we show that these upper bounds are polynomial and optimal

Use of antidepressants and the risk of myocardial infarction in middle-aged and older adults: A matched case-control study

Purpose: Antidepressants, specifically selective serotonin reuptake-inhibiting antidepressants (SSRIs), decrease platelet activation and aggregation in in vitro experiments and could therefore decrease the risk of myocardial infarction (MI). However, prior studies addressing this hypothesis showed contradictory results. Our purpose was to investigate the association between the use of any antidepressant drug and incident MI among middle-aged and older adults. Methods: We embedded a case-control study in the prospective Rotterdam Study (1991-2011). Controls were matched to MI cases based on sex and age at the same calendar date, and confounding factors were taken into account as time-varying covariates. The relative risk of MI during current and past use of an antidepressant was analyzed with conditional logistic regression with never use of antidepressant dr

Reference ranges and determinants of total hCG levels during pregnancy: the Generation R Study

Human chorionic gonadotropin (hCG) is a pregnancy hormone secreted by the placental synctiotrophoblast cell layer that has been linked to fetal growth and various placental, uterine and fetal functions. In order to investigate the effects of hCG on clinical endpoints, knowledge on reference range (RR) methodology and determinants of gestational hCG levels is crucial. Moreover, a better understanding of gestational hCG physiology can improve current screening programs and future clinical management. Serum total hCG levels were determined in 8195 women participating in the Generation R Study. Gestational age specific RRs using ‘ultrasound derived gestational age’ (US RRs) were calculated and compared with ‘last menstrual period derived gestational age’ (LMP RRs) and a model-based RR. We also investigated which pregnancy characteristics were associated with hCG levels. Compared to the US RRs, the LMP RRs were lower, most notably for the median and lower limit levels. No considerable differences were found between RRs calculated in the general population or in uncomplicated pregnancies only. Maternal smoking, BMI, parity, ethnicity, fetal gender, placental weight and hyperem