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Objectives To optimize protamine titration for heparin antagonization after weaning from cardiopulmonary bypass (CPB). Design A prospective, observational trial. Setting Single-center, non-university teaching hospital. Participants Forty patients presenting for elective on-pump coronary artery bypass grafting with or without single valve surgery. Interventions At the end of CPB, the residual amount of heparin in the patient was estimated using a Bull-curve. The total protamine dose was calculated as 1 unit of protamine for 1 unit of heparin. Protamine was administered as 5 aliquots containing 20% of the total protamine dose each, with 2-min intervals. Measurements and main results Activated Clotting Time (ACT) values were measured 2 min after administration of each aliquot. ROTEM(®)-analysis was performed after the full dose of protamine had been administered. After 60% of the total protamine dose had been administered, ACT values were normalized in 86.5% of patients. After the complete dose of protamine had been administered, 61.1% of patients displayed signs of protamine overdose on ROTEM(®)-analysis. Conclusions In patients who present for on-pump coronary artery bypass grafting with or without single valve surgery, a 0.6-to-1 ratio of protamine-to-heparin to antagonize heparin may be sufficient and beneficial for patients.

PurposeThe aim of this study is to shed light on the relative importance of Chinese (Mainland China and Hong Kong: CH-HK) foreign direct investments (FDIs) in real estate (FDIRE) on the dynamics of Asia-Pacific (APAC) public real estate markets after the Global Financial Crisis.Design/methodology/approachUsing a parsimonious real estate asset-pricing model including macroeconomic risk factors, the authors develop a metric to measure FDIs in the real estate sector. The authors use a panel VAR approach based on robust econometric methodology (generalized method of moments) and deal with potential endogeneity and an eventual causality problem. The authors also compute multiple metrics to measure the Chinese, US and Japanese FDIs in the real estate sector.FindingsThe study results report a positive significant impact of CH-HK FDIRE on APAC public real estate returns, while FDIRE originating from outside China are not significant. The authors also show that Chinese investors use the channel of FDIs in Diversified Listed Property Companies (LPCs) and Hotel and Family LPCs to gain exposure to the APAC real estate markets. The study results suggest that APAC property markets are mainly impacted and emphasize the importance of an intercontinental diversification strategy for investors in LPCs in the APAC region.Practical implicationsContrary to Bond et al. (2003) who identified that APAC public real estate markets were overwhelmingly idiosyncratic in the decade preceding China's WTO membership (1990–2001), the study findings underline that Chinese FDIRE became a common factor affecting all eight markets in this study in the decade following the global financial crisis (2007–2017). The results emphasize the importance of an intercontinental diversification strategy for investors in LPCs in the APAC region.Originality/valueThe authors use a parsimonious model, introduce metrics to measure FDIRE and apply a panel VAR approach based on a robust econometric methodology to shed light on China's economic globalization strategy on Asia-Pacific public real estate markets after the GFC. The study results highlighting the major impact of CH-HK FDIRE on securitized real estate market returns dynamics, identify the existence of an Asian common factor driven by Chinese FDI inflows into neighbouring countries.

The implementation of smart technologies in the built environment presents unprecedented opportunities and challenges for the real estate sector. Among the challenges is building occupants’ behavioural control due to smart buildings’ technological apparatus underpinned by pervasive computing. Since the early days of cybernetics, control stemming from information technology has generated many arguments about freedom, privacy and surveillance. Arguments only focused on technology or ethics tend to foster a Manichean view which obscures our ability to rationally assess calm and transparent technology’s role in controlling space users’ behaviours in smart buildings. The paper applies two classic economic frameworks to decipher the economic nature of behavioural control in smart real estate. In the process, it sheds some light on the complex utilitarian relationship between behavioural control and smart space’s user centricity. It concludes by assessing whether regulators should step in, for instance, through de jure property rights allocation among all parties.

Introduction In 2007, the use of aprotinin was temporarily suspended following several publications raising serious safety concerns.(1.2.3) However, Canadian and European Health Authorities concluded that these studies suffered from major flaws and lifted the suspension in 2013.(4,5) The reintroduction of aprotinin in 2016 was accompanied by a mandatory registry [Nordic Aprotinin Patient Registry (NAPaR)] in order to monitor the pattern of use, the effect of risk minimization measures, and overall safety. Objective of this study was to analyse the use of aprotinin in Belgium. Methods NAPaR is a non-interventional Post-Authorisation Safety Study (PASS), endorsed by the Pharmacovigilance Risk Assessment Committee of the European Medicine Agency. Results Between October 2018 and August 2020, six Belgian NAPaR centers included 694 patients [median age 70 (range 13-90y); 62% male; median EuroSCORE II 4.6 (range 0.5-93.4)]. 25% of the patients had an EuroSCOREII > 10. 57% of the patients were under an active antiplatelet therapy and 17% were treated with novel oral anti-coagulants. Preoperative renal impairment was present in 2/3 of patients. Only 4% of the patients received aprotinin on-label, i.e. for isolated coronary artery bypass grafting (CABG) on cardiopulmonary bypass (CPB). In 96% of the patients, aprotinin was used off-label, mainly for redo surgery (32%), CABG + valve surgery (29%), aortic surgery (20%) and multiple valve surgery (17%). One third of the procedures were urgent (23%) or emergent (9%). Median bypass time was 128min (range 13-600min). Median hospital stay was 11 days (range 3-151 days). Main reported indications for the use of aprotinin were active dual antiplatelet therapy (68% in iCABG), redo surgery (16%) and expected prolonged CPB time (55%). In 83% of the cases, aprotinin was administered at the Half Hammersmith dose (1 Mio KIU loading- and priming-dose + 250.000 KIU/h); most patients received the appropriate test dose (98%), none developed anaphylactic reactions. Median perioperative blood loss was 400ml (range 40 -10050 ml), 44% of the patients had RBC transfusion and 6% underwent reoperation for bleeding or tamponade. Overall mortality at discharge was 5%, i.e. within the range or lower than predicted by the EuroSCORE II. 2% of the patients had a postoperative stroke. Postoperative AKI as defined by a serum creatinine increase of 0,3mg/dL or more within 48 hours after surgery was present in 13% of cases. Most of these patients (76%) suffered from preoperative moderate or severe renal impairment including dialysis. Notably, in patients with postoperative AKI median CPB time was significantly higher than in patients without AKI: 172min (range 56-402) vs 125min (range 13-600min) (p Discussion In the Belgian centers, aprotinin was mainly used off-label and predominantly administered to older patients with significant comorbidities undergoing high-risk procedures. The observed safety outcomes are in line with published data within this high risk patient population. The data from the Belgian NAPaR suggest that aprotinin has an excellent safety profile in adult cardiac surgery.