Criteria for Outpatient Management of Proximal Lower Extremity Deep Venous Thrombosis: Complications in Patients Deemed Ineligible for Outpatient TherapyTwo patients in the ineligible group had nonfatal symptomatic PE diagnosed by either high-proba-bility ventilation-perfusion scan (one patient) or pulmonary angiogram (one patient) while being treated for the previously diagnosed proximal lower extremity DVT. Both of these patients had adequate anticoagulation at the time of their PE with an activated partial thromboplastin time of > 1.5 times the control. Another patient in the ineligible group may have had a PE based on clinical suspicion, but a ventilation-perfusion scan was interpreted as intermediate probability and an angiogram was not performed. Read the rest of this entry »

Patients
Twelve hundred patients underwent lower extremity duplex ultrasound scanning during the 1-year period (Fig 1). Of these patients, 203 (17%) were diagnosed as having proximal lower extremity DVT, Of the 199 who had inpatient therapy, 195 had charts available for review, constituting our main study cohort. The mean (± SD) age of the study cohort was 70 (± 16) years with a range of 81 years, Fifty-nine percent of patients were women.
Eligibility for Outpatient Therapy
Thirty percent of patients had the diagnosis of proximal lower extremity DVT made in the outpatient setting, including the emergency department, whereas 70% of patients had the diagnosis made while already hospitalized (Fig 1). Nine percent of the study cohort were eligible for outpatient DVT therapy. Another 9% of the study cohort were possibly eligible. The remaining 82% of patients were ineligible for outpatient therapy. Read the rest of this entry »

Criteria for Outpatient Management of Proximal Lower Extremity Deep Venous Thrombosis: Application of Eligibility Criteria and Determination of Complication RatesApplication of Eligibility Criteria and Determination of Complication Rates
By retrospectively applying the a priori eligibility criteria to the study cohort, we classified patients as eligible, possibly eligible, or ineligible for outpatient therapy (Fig 1). Hospital and laboratory records, ventilation-perfusion and pulmonary angiography reports, and autopsy documents were reviewed to see which patients had complications during their hospitalization for initial proximal lower extremity DVT therapy. For the purposes of this study, the relevant hospitalization began when the DVT was first diagnosed. We defined initial therapy as the period that began when patients received IV unfractionated heparin and ended when patients were converted to oral warfarin therapy for treatment of the newly diagnosed DVT. anti allergy
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Study Setting and Patients
Using a computerized registry, we identified all patients who underwent lower extremity duplex ultrasound scanning between July 1, 1993, and June 30, 1994, in the vascular laboratory at Jewish Hospital at the Washington University Medical Center in St. Louis, MO. Patients were selected for chart review if they had been hospitalized and had a new proximal lower extremity DVT diagnosed by duplex examination. During duplex evaluation, proximal lower extremity DVT was defined as a constant and incompressible intraluminal deep venous defect at or above the popliteal vein. Although all study patients were ultimately hospitalized, the timing of the duplex examination in relationship to hospital admission was used to classify each patient’s presentation as an outpatient or inpatient event. Duplex examinations performed in the emergency department prior to hospital admission were considered as part of an outpatient presentation (Fig 1). Read the rest of this entry »

Criteria for Outpatient Management of Proximal Lower Extremity Deep Venous ThrombosisUnfractionated IV heparin has been used traditionally for the treatment of hospitalized patients who have a newly diagnosed proximal lower extremity deep venous thrombosis (DVT). However, subcutaneously administered low-molecular-weight heparin (LMWH) has been demonstrated to be as safe and effective as therapy with continuous IV unfractionated heparin. The advantages of LMWH over unfractionated heparin include infrequent and subcutaneous dosing and safety without activated partial thromboplastin time monitoring. Given these advantages and their potential for cost savings, LMWHs provide an excellent opportunity for outpatient treatment of patients with uncomplicated proximal lower extremity DVT. Read the rest of this entry »

Characterization of an Animal Model of Ventilator-Acquired Pneumonia: DiscussionHistologic, bacteriologic, and pathogenic aspects of pneumonia in this model resemble early-onset VAP in humans. Regarding standardization of the model, we must admit that the severity of pneumonia by day 4, as assessed by macroscopic examination, lung weight, and alteration in gas exchange was highly variable from one animal to another. However, in most cases, < 30% of the lungs were involved with the pneumonic process. As far as natural history is concerned, since the animals were not killed before day 4, we cannot precisely ascertain when pneumonia started during the time course of MV. In most of the cases, pneumonia became clinically suspected (purulent tracheal aspirates and need for higher Fio2) after 3 days of MV. Once gas exchange began to deteriorate, there was no trend toward spontaneous improvement. We can thus reasonably hypothesize that pneumonia would have extended if MV were continued after day 4. These findings are in accordance with those of Johanson et al in ventilated baboons. buying antibiotics online
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Hemodynamic Status and Electrolyte Balance
In the six animals that did not develop pneumonia, the main hemodynamic parameters remained essentially stable throughout the study period (Fig 5). In the 21 animals that developed pneumonia, the mean arterial pressure showed a progressive and significant decrease from day 1 to day 4 and the pulmonary vascular resistance index significantly increased. However, despite these significant changes, the concomitant changes of cardiac index and systemic vascular resistance index were not consistent with the development of frank shock. Electrolyte balance as judged by daily measurements of usual clinical chemistry (creatinine, urea, serum albumin, total protein levels and electrolytes, and lactate concentrations) remained essentially stable over the study period (data not shown). Read the rest of this entry »

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