Hemorrhagic Complications of Anticoagulant Treatment. part 1

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This chapter about hemorrhagic complications of anticoagulant treatment is part of the seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Bleeding is the major complication of anticoagulant therapy. The criteria for defining the severity of bleeding varies considerably between studies, accounting in part for the variation in the rates of bleeding reported. The major determinants of vitamin K antagonist-induced bleeding are the intensity of the anticoagulant effect, underlying patient characteristics, and the length of therapy. There is good evidence that vitamin K antagonist therapy, targeted international normalized ratio (INR) of 2.5 (range, 2.0 to 3.0), is associated with a lower risk of bleeding than therapy targeted at an INR > 3.0. The risk of bleeding associated with IV unfractionated heparin (UFH) in patients with acute venous thromboembolism (VTE) is < 3% in recent trials. This bleeding risk may increase with increasing heparin dosages and age (> 70 years). Low molecular weight heparin (LMWH) is associated with less major bleeding compared with UFH in acute VTE. UFH and LMWH are not associated with an increase in major bleeding in ischemic coronary syndromes, but are associated with an increase in major bleeding in ischemic stroke. Information on bleeding associated with the newer generation of antithrombotic agents has begun to emerge. In terms of treatment decision making for anticoagulant therapy, bleeding risk cannot be considered alone, ie, the potential decrease in thromboembolism must be balanced against the potential increased bleeding risk.

(CHEST 2004; 126:287S-310S)

Key words: anticoagulant; bleeding; complications; heparin

Abbreviations: AMS = anticoagulation management services; APTT = activated partial thromboplastin time; ASPECT = Anticoagulants in the Secondary Prevention of Events in Coronary Thrombosis; CARS = Coumadin-Aspirin Reinfarction Study; CHAMP = Combination Hemotherapy and Mortality Prevention; CI = confidence interval; DVT = deep vein thrombosis;

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians.

Correspondence to: Mark N. Levine, MD, MSc, Room 104, First Floor, Henderson Research Centre, 711 Concession St, Hamilton, Ontario L8V 1C3 INR = international normalized ratio; IST = International Stroke Trial; LMWH = low molecular weight heparin; NSAID = nonsteroidal anti-inflammatory drug; OR = odds ratio; RCT = randomized controlled trial; SPAF = Stroke Prevention in Atrial Fibrillation; SPIRIT = Stroke Prevention in Reversible Ischemia Trial; SPORTIF = Stroke Prevention Using an Oral Thrombin Inhibitor in Atrial Fibrillation; TIMI = Thrombolysis in Myocardial Infarction; UFH = unfractionated heparin; VTE = venous thromboembolism; WARIS = Warfarin-Aspirin Reinfarction Study.


The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. part 33

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Thus, ximelagatran therapy is a promising alternative to warfarin therapy for stroke prevention in this population. With no need for coagulation monitoring, ximelagatran is more convenient than warfarin, a feature that may increase anticoagulant use in high-risk patients with atrial fibrillation.

Parenteral anticoagulants continue to have a role in the treatment of acute coronary syndromes. The results of the REPLACE-2 trial suggest that bivalirudin obviates the need for GPIIb/IIIa antagonists in the majority of patients with low-to-moderate risk who are undergoing percutaneous coronary interventions, thereby reducing the risk of bleeding.

Fondaparinux and DX9065a have yet to find a place in the treatment of acute coronary syndromes, but further studies are planned. Likewise, NAPc2 is undergoing evaluation for these indications. Although most of the attention has focused on the use of parenteral anticoagulants for short-term treatment, rapidly acting, orally active agents also may have a role in long-term therapy. There is mounting evidence that, despite initial treatment, patients with acute coronary syndromes remain at risk for recurrent ischemic attacks for months after the index event. Some studies have indicated that long-term treatment with the combination of aspirin and clopidogrel is more effective at reducing the risk of recurrent ischemia than aspirin alone. Likewise, long-term warfarin therapy also appears to be effective. We do not yet know whether therapy with aspirin plus clopidogrel is as effective as warfarin therapy, or whether treatment with all three agents can be safely administered on a long-term basis. However, recent results with warfarin raise the possibility that ximelagatran therapy may be useful for this indication, either alone or in combination with antiplatelet agents.

Another unanswered question is the utility of ximelaga-tran in patients with mechanical heart valves. With no need for anticoagulation monitoring, ximelagatran has the potential to streamline the care of these patients, particularly those living in remote areas who cannot access a coagulation laboratory. The anticoagulation management of women with mechanical heart valves during pregnancy also remains a major challenge. If the use of ximelagatran is safe in this setting, treatment would be simplified.


With a large number of new anticoagulant agents in advanced stages of development, our armamentarium of treatment options is likely to soon be expanded. Particularly promising are new oral anticoagulant agents because they have the potential to streamline the long-term prevention and treatment of patients with venous and arterial thrombosis.


Subjects and BAP-65 Classes

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We have previously proposed the BAP-65 (elevated BUN, altered mental status, pulse > 109 beats/min, age > 65 years) system for application in AECOPD. This system is designed to only use information that is generally available to physicians at the time of patient presentation. BAP-65 assigns points based on BUN level, mental status, pulse, and age. In an earlier analysis of nearly 90,000 patients with AECOPD, we demonstrated that BAP-65 correlated with both the need for MV and in-hospital mortality.

In the present study we sought to validate the BAP-65 system in a separate and more recent cohort of patients with AECOPD. We also aimed to explore the usefulness of BAP-65 in a broader population to include AECOPD in patients suffering from acute respiratory failure at the time of presentation. Finally, we attempted to determine how the BAP-65 score correlated with measures of resource use, such as length of stay (LOS) and hospital costs.

Subjects and BAP-65 Classes

We included all people > 40 years of age (to minimize potential patients with asthma) in the analysis with either (1) a principal International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) discharge code of COPD with acute exacerbation (491.21, 491.22, or 496.XX) or (2) a principal ICD-9-CM discharge code of acute respiratory failure (518.81) along with a secondary discharge code of COPD. We further restricted the eligible population to diagnosis-related groups (DRGs) (version 27) 190, 191, 192 (COPD), or DRG 189 (pulmonary edema or respiratory failure), or any of the four DRGs indicating that MV was performed in the index hospitalization (DRG 207, 208, 3, or 4). The analytic units were admissions.

The BAP-65 system is based on information available on initial hospital presentation. For patients who have none of the three main risk factors (BUN level > 25 mg/dL, altered mental status, or pulse > 109 beats/min), those < 65 years of age are designated as class I, whereas patients with no risk factors who are >65 years of age are classified as class II.


Diabetes Specialists in Health Care Mall

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The therapy of Sort II diabetes calls for a team approach. Numerous diabetics do not have a group of pros to aid them control their diabetes or even give them worthwhile data on their situation. Diabetics are typically ill informed on the many pros that are offered and who can support them handle their situation.

There are a quantity of specialists who specifically deal with diabetes and are specifically certified to operate with individuals with Variety II diabetes. The following is a list of specialists that are obtainable to assist you with your situation.

Health-related physician
Nurse educator
Registered dietitian
Eye doctor
Social workers
Exercising physiologist
Functional endocrinologist

People are often shocked to see that chiropractors are a portion of well being care specialists that can assist diabetics. Chiropractors are in fact required to have nutrition education as portion of their degree, which makes them specifically qualified to work with Sort II diabetes sufferers. Chiropractors are necessary for patients suffering from diabetes because nutrition is a huge element of controlling diabetes. With correct nutritional suggestions, many people with Variety II diabetes are able to take back handle of their lives as well as reverse some of the damage triggered by diabetes.

A lot of chiropractors, naturopathic medical doctors and some health-related medical doctors today are explicitly trained in functional endocrinology. This indicates that they have an intricate knowledge and understanding on how the distinct organ systems operate and also establish which organs are not working as they need to. Functional endocrinologists are a necessity if you are to have a Health and Care-related group that is capable to successfully handle your diabetes. Medications for treatment diabetes you can see here: www.healthcaremallofficial.com.

A traditional endocrinologist uses blood function and your blood sugar levels to figure out what medication is required to handle your diabetes. A wellness professional that practices functional endocrinology on the other hand appears at the identical blood sugar levels on the blood function and seeks as an alternative to establish what brought on them to be high or low in addition to helping you control your blood sugar levels. A health professional that practices functional endocrinology is more likely to get to the source of the problem and then effectively function towards reversing it. This also benefits in significantly much better outcomes for a person suffering from Kind II diabetes.



What is diabetes and Cauases

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I have just been diagnosed with Type 2 diabetes and my doctor says it is because I have something called the Metabolic Syndrome. What does this mean and is it the cause of my diabetes?  What is diabetes

Metabolic syndrome is a group of conditions that are known to increase the risk of heart disease and stroke. There are a number of different definitions but they all emphasise that insulin resistance is the underlying cause. The cluster of problems called metabolic syndrome includes the following:

  • central obesity (fat around the waist line)
  • high blood pressure
  • abnormal cholesterol (high LDL and low HDL fractions) and high levels of triglycerides
  • Type 2 diabetes, impaired glucose tolerance (see link) – or at least a high risk of developing this
  • fatty liver (see next question)

The insulin resistance means that if a person with metabolic syndrome does not have diabetes, their beta cells in the pancreas will be working overtime to produce high levels of insulin in order to keep the blood sugar level normal. There is a high chance that the beta cells will be unable to maintain this high output of insulin indefinitely and sooner or later the blood sugar level will rise, resulting in diabetes.

People with metabolic syndrome, whether or not they have diabetes, will probably be asked to take a number of tablets in order to correct the high blood pressure and abnormal cholesterol levels. The best treatment (though not always the easiest) is to reduce weight and overcome the central obesity.

My doctor carries out regular tests for diabetes. This is because I have a condition called fatty liver, which he says puts me at risk of developing diabetes in the future.

The medical name for this condition is Non-Alcoholic Fatty Liver Disease (NAFLD) and it describes a range of conditions in which the liver tests are abnormal in people who drink little or no alcohol. It ranges from a mild condition in which excess fat is deposited in the liver causing slightly abnormal liver tests to a more serious condition in which the fat in the liver leads to inflammation, scarring and cirrhosis, which is irreversible liver damage. NAFLD is very common and may be found in up to 1 in 5 adults. Of those with NAFLD, about 1 in 4 will develop the more serious form leading to cirrhosis. This is a very slow process and may progress over years to liver failure. It is related to obesity and as in the metabolic syndrome (see previous question) insulin resistance is the underlying cause. There is no proven treatment for this condition, apart from weight reduction, which results in rapid improvement in the abnormal liver tests. However in trials glitazones have been shown to improve liver tests and are beginning to be used in ordinary practice. Unfortunately they do have the effect of making people put on weight, which is often disappointing.


Diabetes Education

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Most people diagnosed with Type 2 diabetes respond at first to changes in their diet. This alone may have a dramatic effect on their condition, especially in people who are overweight and manage to get their weight down. If changes in diet fail to control diabetes, tablets will be needed, but these will not work indefinitely and once they fail, insulin is the only alternative. A small number of people with Type 2 diabetes, who feel very unwell at the time of diagnosis, may need insulin immediately.

The most important thing for anyone with newly-diagnosed diabetes is to access good diabetes education. In the past, people were often given instructions about what to eat and which Kamagra tablets to take without any explanation as to why it was important. Not surprisingly, they did not always follow the advice. The importance of structured education has been recognised in the national frameworks for diabetes, and education programmes have been developed for both Type 1 and Type 2 diabetes. The DAFNE programme was introduced for Type 1 diabetes in 2002, and following its success, a group of people interested in diabetes education started to develop a course for people with Type 2 diabetes. They devised the DESMOND programme – Diabetes Education Self Management Ongoing and Newly Diagnosed. DESMOND is available in 110 healthcare areas in UK and Ireland. While still designed for newly diagnosed patients with type 2 diabetes, the ongoing programme is now being put through trials. Eventually everyone with Type 2 diabetes should have access to a standardised education programme, which will help them to understand diabetes and make important decisions about lifestyle changes.

My doctor has just told me that I have diabetes and I am feeling very shocked and confused as I don’t know much about it but I know it can be serious. My doctor has given me the telephone number of Diabetes UK so I can get more information but I would really like to talk to someone with diabetes. Can you help me?

Most people who are told they have diabetes feel very upset at the news. One of the problems is the uncertainty about exactly how diabetes will impinge on their life. We agree that a phone call to Diabetes UK helpline is a good idea; it has gone to a lot of trouble to produce useful information for people with newly diagnosed diabetes. However, the most important thing they can do is put you in touch with the local branch of Diabetes UK. Naturally these vary in their level of activity, but in some areas the local branch is very well organised to provide support and information to new members. This will give you the opportunity to speak to other people who are in the same boat.

Some GP practices have set up programmes for people with newly diagnosed diabetes and practice nurses are committed to providing high quality support.

What would really help you is group education, which has the added advantage of giving people the opportunity to share their experiences and provide mutual support. More areas are providing group education sessions and we hope that in the next few years structured education will be available to everyone with Type 2 diabetes.

Canadian News and treatment Premature ejaculation on this website: http://www.acanadianhealthcaremall.com


The ACCP Conference on Antithrombotic and Thrombolytic Therapy

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Long-term anticoagulation therapy is of benefit in patients with unprovoked venous thromboembolism. There is increasing evidence that the risk of recurrent venous thromboembolism in these subjects is about 7 to 10% per annum if anticoagulant therapy is stopped after 3, 6, 12, or 27 months. Although long-term warfarin therapy markedly reduces the risk of recurrence, its benefit is offset, at least in part, by the risk of major bleeding, which is estimated to be about 1 to 3% per annum. Furthermore, because of multiple food and drug interactions, the anticoagulant response to warfarin is unpredictable so that frequent monitoring is necessary to ensure that a therapeutic response has been obtained. In contrast, ximelagatran therapy does not appear to require coagulation monitoring and, at least with the dose used in the THRIVE III trial, ximelagatran appears to be safe. Despite these promising results, the role of ximelagatran in extended thromboprophylaxis has yet to be established. Thrombolytic Therapy

The ximelagatran treatment study has suggested that ximelagatran monotherapy is as effective and safe as the current treatment regimens for venous thromboembolism. If these results are confirmed in other studies, ximelaga-tran has the potential to streamline care by obviating the need for initial treatment with a parenteral anticoagulant and the coagulation monitoring that is required when warfarin is administered. Still to be determined is the effectiveness of ximelagatran in high-risk patients, such as those with advanced cancer or with antiphospholipid antibody syndrome Myviagrainaustralia.com.

4.2 Arterial thrombosis

Like venous thromboembolism, issues in arterial thromboembolism focus on prevention and treatment. The prevention of cerebral and systemic embolism in patients with atrial fibrillation is an area in which there is considerable room for improvement. Although warfarin is more effective than aspirin in reducing the risk of embolization in this setting, its use is problematic. Frequent monitoring is necessary to ensure that a therapeutic anticoagulant response is obtained. Even with monitoring in specialized clinics, the level of anticoagulation is outside the therapeutic range almost half of the time. Furthermore, the risk of major bleeding with long-term treatment with Sildenafil citrate increases in the elderly, the population that is most at risk for atrial fibrillation. Because of these problems, it is estimated that warfarin is not given to almost half of the eligible atrial fibrillation patients. Based on the results of the SPORTIF III trial and the SPORTIF V trial, unmonitored ximelagatran therapy appears to be at least as effective and safe as dose-adjusted warfarin therapy.


Hospital admissions for asthma over the past year

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PEFR is expressed as percentage of a patient’s predicted value, based on age, gender, and height. Changes in PEFR are expressed as the absolute change in percent predicted (ie, final PEFR as percent predicted minus initial PEFR as percent predicted). Asthma-related ED visits and urgent clinic visits over the past year were treated as continuous variables. A high percentage of subjects had no hospital admissions for asthma over the past year (74%) and this was therefore treated as a dichotomous variable.

Triggers of the patient’s asthma, in general, were assessed using a standardized list of potential triggers: respiratory tract infections, environmental allergens, other environmental factors, tobacco, exercise, ingested substances, reproductive, psychosocial, and other factors Online pharmacy viagra. The individual triggers as well as total number reported (range, 0 to 9) were recorded. Relapse was defined as any urgent or unscheduled visit to any physician for worsening asthma symptoms during the 2-week follow-up period.

All analyses were performed using software. Data are summarized using proportions, mean ± SD, and median with interquartile range (IQR). Univariate analyses of the relation of various factors to risk for relapse employed test, Student’s t test, and Wilcoxon rank sum test where appropriate. Variables that were associated with relapse at a two-tailed p < 0.1 in univariate analysis were evaluated for inclusion in a multivariate logistic regression model. This model was built with both forward and backward steps but was not done using the stepwise software function. Initially, variables were grouped into categories and assessed for colinearity by Spearman correlation and simultaneous inclusion in logistic regression models.

Variables that were independently associated with relapse in these initial models were included in the model building process. When groups of similar variables showed significant colinearity, with no single variable attaining statistical significance in the initial logistic regression model, a representative variable from each group that showed the strongest association with relapse was chosen for inclusion in the model building process. The final model included all independently associated variables as well as age, gender, and race, which were chosen for their clinical significance. The possibility of a period effect was examined by adjusting for period of enrollment, but this did not materially.


Validation of a Novel Risk Score for Severity of Illness in Acute Exacerbations of COPD

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Background: Clinicians lack a validated tool for risk stratification in acute exacerbations of COPD (AECOPD). We sought to validate the BAP-65 (elevated BUN, altered mental status, pulse > 109 beats/min, age > 65 years) score for this purpose.

Methods: We analyzed 34,699 admissions to 177 US hospitals (2007) with either a principal diagnosis of AECOPD or acute respiratory failure with a secondary diagnosis of AECOPD. Hospital mortality and need for mechanical ventilation (MV) served as co-primary end points. Length of stay (LOS) and costs represented secondary end points. We assessed the accuracy of BAP-65 via the area under the receiver operating characteristic curve (AUROC).

Results: Nearly 4% of subjects died while hospitalized and approximately 9% required MV. Mortality increased with increasing BAP-65 class, ranging from < 1% in subjects in class I (score of 0) to > 25% in those meeting all BAP-65 criteria (Cochran-Armitage trend test z = —38.48, P< .001). The need for MV also increased with escalating score (2% in the lowest risk cohort vs 55% in the highest risk group, Cochran-Armitage trend test z = —58.89, P < .001). The AUROC for BAP-65 for hospital mortality and/or need for MV measured 0.79 (95% CI, 0.78-0.80). The median LOS was 4 days, and mean hospital costs equaled $5,357. These also varied linearly with increasing BAP-65 score.

Conclusions: The BAP-65 system captures severity of illness Generic pharmacy viagra and represents a simple tool to categorize patients with AECOPD as to their risk for adverse outcomes. BAP-65 also correlates with measures of resource use. BAP-65 may represent a useful adjunct in the initial assessment of AECOPDs.

Abbreviations: AECOPD = acute exacerbations of COPD; AUROC = area under the receiver operating characteristic curve; BAP-65 = elevated BUN, altered mental status, pulse > 109 beats/min, age > 65 years; DRG = diagnosis-related group; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; IQR = interquartile range; LOS = length of stay; MV = mechanical ventilation

COPD represents the fourth most common cause of death in the United States.


Embolism scores exist to aid in the management of acute pulmonary embolism

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Beyond its impact on mortality, COPD leads to considerable morbidity. Acute exacerbations of COPD (AECOPDs) contribute to the disproportionate health burden of COPD. AECOPDs present a short-term risk for death and result in an accelerated decline in lung function. Patients often do not suffer a single exacerbation but tend to experience multiple exacerbations over their lifetimes. Furthermore, AECOPDs are a common reason for nonsurgical hospitalization and account for approximately one-half of the direct medical costs related to COPD.

AECOPDs can range in severity from mild to life threatening. Physicians can treat some individuals safely as outpatients. Other subjects may require mechanical ventilation (MV) for respiratory failure. In addition, some with AECOPD may initially respond to therapy but then decline. Unfortunately, clinicians lack a simple, validated risk-stratification tool for assessing the likely prognosis and severity of AECOPDs. For other diseases that share these features of variability in disease severity and the potential for a rapid change in patient status, clinicians can use various risk-stratification schemes. For example, both the Pneumonia Severity Index and the CURB-65 (confusion, urea, respiratory rate, BP) score serve as easy-to-apply and reliable severity-of-illness scoring rubrics in community-acquired pneumonia. The Pulmonary Embolism Severity Index and the Prognosis in Pulmonary

Embolism scores exist to aid in the management of acute pulmonary embolism. Unfortunately, although risk-assessment tools exist for patients with stable COPD, none have been validated for use in AECOPD.

A disease-specific severity-of-illness score for AECOPD would serve to improve treatment. It would facilitate triage decisions and identify patients who might potentially benefit for early and aggressive use of selected interventions, such as noninvasive ventilation. A reliable severity-of-illness score could also be applied in clinical trials. It would provide a standardized means for describing the patients studied while helping to ensure that the populations in these trials were well balanced with respect to disease severity.