Reference values for spirometry of the European Coal and Steel Community: time for change.

REFERENCES 1 Davies CW, Wimperis J, Green ES, et al. Early discharge of patients with pulmonary embolism: a two-phase observational study. Association between thrombolytic treatment and the prognosis of hemodynamically stable patients with major pulmonary embolism: results of multicenter registry. Predicting adverse outcome in patients with acute pulmonary embolism: a risk score. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcu-taneous low-molecular-weight heparin administered at home. Prognostic models for selecting patients with acute pulmonary embolism for initial outpatient therapy. validation of a prognostic model for pulmonary embolism. We would like to thank R. Otero and D. Jiménez for their comments and their support for the principle of outpatient management of pulmonary embolism (PE). However, we are surprised by the tone of their letter. We believe that patients should be considered for ambulatory care for the management of PE after appropriate risk stratification. This can take many forms, such as the criteria developed and used by my group, or use of validated prognostic scores, e.g. PE severity index scores. As stated in the original paper, this score gives a prediction of 30-day mortality rather than the more useful prediction of mortality within the acute low-molecular heparin treatment phase relevant to outpatient treatment of PE, and was also unpublished at the time the study was developed or performed [1]. Systolic arterial hypertension is a prognostic marker and relates to massive or submassive PE. As such, the patients in our study would fulfil other exclusion criteria given in points 1) and 2) of the Exclusion criteria for outpatient treatment section in the Methods of the original article [1]. The number of deaths reported in the data of R. Otero and D. Jiménez suggest that the population in this database who fulfilled our study criteria were somehow different to the actual patients we prospectively sent home for outpatient treatment. This highlights the fact that caution is needed when retrospectively trying to draw conclusions from applying exclusion criteria to a database cohort compared with a prospective cohort. Patient data suggests that patients prefer to be managed in an ambulatory fashion. Therefore, we believe that with appropriate risk stratification and patient information, we should offer this service to patients who fulfil the criteria quoted in our study [1]. REFERENCES 1 Davies CWH, Wimperis J, Green ES, et al. Early discharge of patients with pulmonary embolism: a two-phase observational study. …