The Health Care Profession Has Changed Over Years

The Health Care Profession Has Changed Over Years
The health care profession has dramatically changed over years in an attempt to improve patients'
outcome. For this reason, nurses have to be aware of rising health care issues as well as evidence–
based recommendations that can improve these problems. Rising health care issues that are being
explored include the advantage of pharmacological treatment based on individuals' genetic makeup,
the rise of urinary tract infections (UTIs), as well as recommendations for preventing heart disease
in women. The idea that human beings are as different to one another as they are alike is not new
and these differences are related to the genetic make–up of each individual. Because all human
beings are not identical, one can safely assume that ... Show more content on Helpwriting.net ...
Clopidogrel can be prescribed prophylactically to high–risk patients or to those who have
experienced atherothrombotic events such as strokes, acute coronary syndrome, peripheral arterial
diseases or any other thrombi–producing illnesses (Cheek, 2013). Clopidogrel works by inhibiting
the binding of adenosine diphosphate to platelet receptors, thus, disrupting the process of platelet
formation and preventing platelet aggregation and thrombi formation. However, in order to inhibit
the binding of ADP, clopidogrel has to be converted to its active form by the enzyme CYP2C19*1.
Unfortunately, some people have lost the ability to produce enzyme CYP2C19*1 and instead
produce a variant form known as CYP2C19*2. CYP2C19*2 cannot convert clopidogrel to its active
form, making clopidogrel useless in patients who carry gene CYP2C19*2. Providentially,
pharmacogenomics can identify variant genes with DNA sequencing prior to prescribing
medications in order to assure the effectiveness of pharmacologic therapy. This also helps health
care providers to prescribe alternate medications when appropriate. Other drugs of research include
the anticoagulant warfarin, the antiretroviral agent abacavir, and the antibody trastuzumab. All these
drugs have genetic variant forms that can affect the effectiveness of pharmacological therapy.
Warfarin is a vitamin K antagonist used to prevent thromboembolic disorders. Another major area of
concern is the growing crisis of
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A Non St Elevation Acute Coronary Syndrome
In the management of an NSTE–ACS patient who underwent early PCI, is there any distinction
between Plavix and Brilinta in reducing thrombotic CV events?
By
Lucia A. Garza
Master's Project
Submitted in Partial Fulfillment of the
Requirements for the
Degree of:
Masters in Physician Assistant Studies
University of Texas Rio Grande Valley
College of Health Sciences & Human Services
Department of Physician Assistant Studies
Edinburg, Texas
December 2015
Abstract:
A non–ST elevation acute coronary syndrome (NSTE–ACS) is a very common presentation to
emergency departments everywhere, as well as primary care practices. Therefore, it is important that
all providers be well informed on the effectivity of certain treatment regimens. ... Show more
content on Helpwriting.net ...
Research shows that due to the greater frequency of PCI in various trials, Brilinta was showed to
have greater benefit over Plavix in NSTE–ACS patients.
NSTE–ACS blah blah and mention statistics and other sources. This research involving current
literature was conducted to determine if there is any difference in antiplatelet therapy with Plavix,
when compared to Brilinta. With this knowledge, providers can be properly informed about
choosing the best treatment for their patients.
Methods:
In order to conduct this research paper, access was gained into the University of Texas Rio Grande
Valley library website (http://www.utpa.edu/library). Under the heading of 'Articles and Databases',

Pub Med was selected. Entering the key–words'Brilinta', 'NSTE ACS' and 'Brilinta vs Plavix' this
search was conducted. This search was conducted on several separate occasions. Over 350 articles
were returned with these key–words mentioned in the title.
After the initial search, about 35 journal readings had to be read thoroughly and closely analyzed.
From which, 10 of these journal articles were deemed pertinent to this manuscript. These
publications were then saved, printed, and re–analyzed for key information. All publications were
chosen from reputable sources via online and only pertinent information relating to this manuscript
will be discussed.
Results:
NSTE–ACS is a diagnosis a provider should never miss.

Sample Resume : ' Pharmacotherapy Workup Notes Care Plan '
Student Name: Yeosmize Student No.: 1023018
Pharmacotherapy Workup © Notes Care Plan
Patient Initials: QB Date: Aug 20, 2016
Medical condition
Gastric ulcer
Patient History: QB is a 79 year–old man who presented to the pharmacy to pick up his prescription
for rabeprazole 20mg, 1 tablet once daily. QB is diagnosed with gastric ulcer. His symptoms are
nausea, vomiting, stomach fullness, and bloating. His other medical conditions are: acute coronary
syndrome and osteoporosis. His current medications are: aspirin 81mg (1 tablet once daily),
clopidogrel 75mg (1 tablet once daily), amlodipine 5mg (1 tablet once daily), trandolapril 2mg (1
tablet once daily), rosuvastatin 20mg (1 tablet once daily), and ACT–Etidrocal (etidronate
400mg/calcium carbonate 500mg). His current blood pressure is normal. QB eats healthy–balanced
diet every day. He occasionally drinks tea or coffee. QB does not smoke or use any recreational
drugs. QB does not take any natural health products.
N: Gastric ulcer is the painful sores that are found inside the lining of the stomach. It can be caused
by H.pylori or medications (ASA, NSAIDs, biphosphonates). Lifestyle such as smoke, alcohol and
spicy foods can increase the risk of gastric acid development. Symptoms of gastric ulcer are
stomach pain, nausea, bloating, feeling fullness and/or heartburn. If it is left untreated, it can
develop to gastric bleeding, severe

Client Profile Assignment
Client Profile Assignment As nurses we deal with several different patients in a day and it is
important to understand the patient as a whole person to treat them effectively. The purpose of this
assignment is to explore a patients disease to understand the nursing judgments and interventions
that go with this patient, to understand medications for this diagnosis, and to understand the disease
the patient was diagnosed itself. The patient described in this paper will be referred to as Jonathan to
ensure patient confidentiality. Demographics Jonathan is a 63 year old man, born on August 23rd,
1956 and lives with his eldest son. He was married two times and has three children, two children
from his first marriage and one from his second. He lives in northern Ontario but originally was not
born here, he moved here shortly following his second divorce. He is of Italian decent and is a
practicing Catholic. The patients weight is 95 kilograms; he is 178 centimeters all and has a body
mass index (BMI) of 28.3. Jonathan says he smokes around one pack of cigarettes a day, does not
get a lot of exercise and eats fast food a few times a week. The patient now has congestive heart
failure as a consequence of his MI. He was transferred from another hospital in the beginning of
November and currently is waiting for more testing before he can be discharged from the hospital or
moved to another facility. The patient has some known comorbidities that can exacerbate his CHF,
this includes

Growth Matrix Of Ansoff
To assess the growth and business strategy of Pfizer & Bristol–Myers Squibb, we will make use of
Ansoff's growth matrix. Ansoff's growth matrix is a valid way to find out which business strategy
and growth strategy the business use. The model states which strategy or strategies a company has
adopted in order to grow. According to Ansoff there are four possible alternatives a company can
use:
· Market Penetration – the company seeks to achieve growth within its existing products in their
current market segments, thereby aiming to increase its initial market share.
· Market Development – the company seeks growth by aiming its existing products towards new
market segments.
· Product Development – the company seeks to develop new products and target these to its existing
market segments.
Diversification – the company seeks to achieve growth by diversifying into new businesses, by
developing new products for new markets. (Johnsson, G. ... Show more content on Helpwriting.net
...
This currently mean, that the companies have adopted a very risky way of growth since this strategy,
as before mentioned, is about developing new products for new markets. This is risky due to lack of
knowledge about markets and manufacturing. The ways in which the companies have pursued this
strategy is by M&A's, which only adds more risk, since many factors may affect the mergers &
acquisition negatively. Furthermore did we find out that in general the pharmaceutical companies
will more or less always work in risky environments, which are also those that generate the highest
amounts of possible revenue, but also those that are in the highest risk for failure. Normally what is
seen, as the highest failure in the pharmaceutical industry is the lack of FDA approval of
pharmaceuticals, very few drugs are granted permission to be marketed each

Plavix Case Study Essay
Patent Games: Plavix Case Study
Columbia Southern University
Abstract
This case study illustrates the conflict between patent protection and preserving a pure competitive
market. Pharmaceutical companies are granted patent rights to newly developed drugs for a limited
amount of time. Through legal means they are able to form monopolies and maximize their profits. a
parent company can move to delay the release of its generic comparison through legal and illegal
measures. In the following case Bristol–Myers Squibb fell victim to their own anti–competitive
practices.
Why did Bristol–Myers Squibb and Sanofi–Aventis seek a settlement? Apotex had was near the
conclusion of the government mandated 30 month stay brought on by ... Show more content on
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Sherman's strategy
Bristol–Myers Squibb's deceptive practices were likely to catch up to them. This occurred when
they crossed paths with Sherman who led Apotex at the time. After everything settled Sherman
acknowledged in an interview that he knew the FTC would reject the proposed agreements made by
Bristol–Myers Squibb and Sanofi. He also recognized that their spokesman didn't realize his offer
would cause adverse action against Bristol–Myers Squibb (Baron, 2010). He played to their
ignorance and entered the agreement. There is no direct answer to the ethics of Sherman's strategy.
He did not actively participate or even condone Brisol–Myers Squibb's collusion; in fact he knew
the agreement would be rejected. There is no way of truly knowing whether Sherman acted with
malice when implementing his strategy.
Should the FTC and the state attorneys general have rejected the agreements? The FTC and state
attorney was right in rejecting Brisol–Myers Squibb's proposed agreements on the grounds that it is
an anti–competitive practice. The second agreement would have been rejected as well provided
Bristol–Myers Squibb was completely honest with the FTC. Upon submission of the second
agreement to the department of justice they affirmed under oath that all agreements were as listed on
the document with no side arrangements (Chen, 2011). After the initiation of an investigation
conducted by the Federal Bureau of Investigations

Research Paper On Clopidogrel Bisulfate
Clopidogrel bisulfate is an oral antiplatelet agent that is used in the treatment of coronary artery,
peripheral vascular, and cerebrovascular diseases. This medication thins your blood to reduce blood
from clotting. The trade name for Clopidogrel is plavix. It is used to prevent heart attacks and
strokes in persons who have had heart disease or previously had a heart attack. It works by helping
to keep the platelets in the blood from sticking together and forming clots that can occur with certain
medical conditions. It is inactive in vitro, and a hepatic bio transformation is necessary for the
medication to work to the fullest of its ability. It is marketed by Bristol–Myers Squibb and Sanofi–
Aventis under the trade name Plavix and licensed

Is AAs Effective As Clopidogrel For The Patient With...
Is prasugrel as effective as clopidogrel for the patient with acute coronary syndrome? Acute
coronary syndrome (ACS) is the most common form of cardiovascular disease.1 In 2006, about
733,000 ACS patients were discharged from hospitals costing the United States $150 billion
annually.2 Eighty percent of these cases were either unstable angina (UA) or no ST– elevation
myocardial infarction (NSTEMI), and the remaining 20% were ST–elevation myocardial infarction
(STEMI). The pathophysiology of ACS includes the stable plaque forms get converted into unstable
plaque forms.2 These unstable plaque forms have numerous thin fibrous cap cells, inflammatory
cells, activated macrophages, and smooth muscle cells. Sympathetic activity increases myocardial
contractility, pulse rate, blood pressure, and coronary blood flow which leads to plaque rupture or
fissure. As the artery ruptures, it causes thrombus formation and ischemia in this particular artery.
Depending on the condition, different thrombi could form. The unstable angina forms a small
thrombus formation, NSTEMI forms a partial thrombus formation, and STEMI forms a complete
and persistent thrombus. The risk factors involved in ACS are age, physical inactivity, and history of
hypertension, diabetes, or angina. The signs of acute coronary syndromes are an acute heart failure,
tachycardia, bradycardia, or heart blockage, and the symptoms of ACS consist of chest pain, pain in
the extremities, nausea, shortness of breath, heavy

The Human Body System Is Not Immune For Pathological...
Our body system is not immune to pathological deficiencies. There exist numerous identified
pathologies which compromise the regular functioning of a heart, but all heart–related pathologies
are narrowed to a single condition known as Acute Coronary Syndrome (ACS). This is the term
formally used in reference to the different identified clinical entities threatening the cardiovascular
system. ACS is the result of the progressive or complete sudden blocking of the arteries or veins;
this prevents an appropriate blood flow through the circulatory system, and as a consequence, the
body is unable to receive enough oxygen and nutrients to meet its daily necessities.
This makes ACS a life–threatening form of coronary heart disease (CHD) that ... Show more content
on Helpwriting.net ...
In a hospital setting, anticoagulants and antiplatelets are widely prescribed by physicians because of
their greater benefits in changing the physiological homeostasis of the cardiovascular system.
Anticoagulants and antiplatelets play a fundamental role in the treatment of cardiovascular diseases
as they are very effective at counteracting the different symptoms cardiovascular diseases present.
Today, suggested treatments depend on patients' health and type of ACS condition. Such treatments
range from invasive surgery for high risk patients to prescribed medications for low risk patients.
The medications vary in function and purpose. For example, thrombosis is the fast forming of an
abnormal blood clot in an artery or vein. Therefore, it must be treated with a fast acting
anticoagulant which could be Heparin or Fondaparinux (Hyers, 2005). Atrial fibrillation is an
abnormal heartbeat and is frequently treated with another type of anticoagulant, Warfarin. Finally,
unstable angina is a chest discomfort caused by the lack of blood flow through the heart and in most
cases is treated with the most common antiplatelet medication, Aspirin.
Anticoagulants are given to prevent blood from clotting or prevent an existing clot from more
growing. In contrast, antiplatelets are only given to prevent blood from clotting. Beside the
advantages each treatment gives patients, none treatment

Importance of Bio Equivalence Studies
Vol. 20, No. 2, May 2011
Clopidogrel copy products in Indonesia are bioequivalent to Plavix® 149
The importance of bioequivalence study: focus on clopidogrel
Arini Setiawati
Department of Pharmacology & Therapeutics, Faculty of Medicine, University of Indonesia,
Jakarta, Indonesia
Abstrak
Studi bioekivalensi (BE) diperlukan untuk menunjukkan apakah suatu produk copy dapat
menggantikan produk inovator. Tujuan makalah ini adalah untuk menjelaskan alasan melakukan
studi BE, produk–produk utama yang memerlukan studi BE, serta desain dan pelaksanaan studi BE,
dengan fokus pada klopidogrel. Semua produk generik klopidogrel di Indonesia telah ditunjukkan
bioekivalen (BE) dengan produk inovatornya, Plavix®, dan mereka mengandung bahan ... Show
more content on Helpwriting.net ...
The D, M, and E are constant within the same subject, therefore differences in the plasma
concentration (= the therapeutic effect) are due to differences in the amount of drug absorbed, or in
other words depends on the delivery of drug from its formulation. Thus, the therapeutic effect
depends on the bioavailability (BA) of the drug product, and therefore bioequivalence means
therapeutic equivalence. Before discussing bioequivalent of a product, we will ﬁrst discuss what is
bioequivalence (BE), therapeutic equivalence (TE), main products requiring BE, as well as design
and conduct of BE studies in general. What is bioequivalence (BE)1. There are some deﬁnitions.
Bioavailability (BA) is the amount of drug, in percentage of dose, which is absorbed and reaches the
systemic circulation (bioavailable) in unchanged/active form. Bioequivalence (BE) is equivalence
bioavailability of 2 drug products with pharmaceutical equivalence or pharmaceutical alternatives.
150 Setiawati
Med J Indones
Pharmaceutical equivalence is if both drug products contain the same amount of the same active
substance in the same dosage forms. Pharmaceutical alternatives if both drug products contain the
same amount of active moiety but differ in the chemical form (salt, ester, etc.) or in the dosage from
(tablet, capsule, etc.) Therapeutic equivalence (TE) is equivalent therapeutic effect of 2 drug

The Common Cause Of Death For American Citizens
Introduction Our body system is not immune to pathological deficiencies. There exist numerous
identified pathologies which compromise the regular functioning of a heart, but all heart–related
pathologies are narrowed to a single condition known as Acute Coronary Syndrome (ACS). This is
the term properly used in reference to the different identified clinical entities threatening the
cardiovascular system. ACS is the result of the progressive or complete sudden blocking of the
arteries or veins; this prevents an appropriate blood flow through the circulatory system, and as a
consequence, the body is unable to receive enough oxygen and nutrients to meet its daily
necessities.
This makes ACS a life–threatening form of coronary heart disease (CHD) that involves three mayor
types of conditions: unstable angina, thrombosis, and atrial fibrillation. Even though there are many
other conditions for ACS, these three are the most common causes of death for American citizens.
This syndrome has become a serious issue in the last decade. Many people are unaware of what
ACS is and how dangerous it is. ACS is responsible for the death of about 600,000 people only in
the United States alone–that is 1 of every 4 deaths. Around other parts of the world, ACS was
projected by the World Health Organization (WHO) to become the single largest cause of death
worldwide by the year 2020 (Lu and Nordin, 2013).
Today, suggested treatments depend on patients' health and type of ACS condition. Such

Clopidogrel And Hip Fractures : A Systematic Review
Clopidogrel and Hip fractures: A Systematic Review Christopher G.K.M. Soo*, Paul Della Torre**,
Michael Shatwell≠ *Orthopaedic surgery department, Port Macquarie Base Hospital **Orthopaedic
surgery department, Concord Repatriation Hospital ≠Orthopaedic surgery department, Port
Macquarie Base Hospital Correspondence Dr Christopher Soo: 121 Carlisle Ave, Blackett, NSW
2770, Australia Email: gavin.soo@gmail.com Fax: +612 96284242 C. G. K. M. Soo MB BS P.
Della Torre FRACS, FAOrthoA M. Shatwell Authors declare that there are no conflicts on interests,
and they are not in receipt of any research scholarships or funding for this paper Key Words
orthopaedics, clopidogrel, anticoagulant, surgical blood loss, hip fracture ... Show more content on
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Studies were identified by searching the Cochrane database, MEDLINE, EMBASE, Google scholar
and bibliographies of relevant published articles. The primary outcome measures were the number
of allogeneic blood transfusion exposures, the units transfused per patient, the postoperative
haemoglobin and the mean drop in haemoglobin levels. Results A total of 4219 studies were
identified. After removal of duplicates and after exclusion criteria were applied, there were 13
studies to be included. All 13 were case series with controls. Conclusions Most of the literature is
made up of low quality retrospective non–randomised cohort studies with small sample sizes.
Ultimately, large multi–centred, adequately powered, well–designed randomised trials are needed to
establish clearer guidelines for the management of these patients. On the available evidence, we
recommend that these patients can be managed by normal protocols with early surgery. Operating
early on patients on clopidogrel is safe and does not appear to confer any clinically significant
bleeding risk. As reported in other studies, we believe clopidogrel, if possible, should not be
withheld throughout the perioperative period due to increased risk of cardiovascular events
associated with stopping clopidogrel. However these medically higher risk patients should be
monitored closely in the perioperative period and care must be taken intraoperatively to minimise
blood loss due

Client Profile Assignment : Nurse 's Care Essay
Client Profile Assignment Nurse's care for several patients in a day and it is important to understand
the patient as a whole person to treat them effectively. The purpose of this assignment is to explore a
patient's disease to understand the nursing judgments and interventions involved, the medications
for this diagnosis, and to understand the disease. The patient described in this paper will be referred
to as Jonathan to ensure patient confidentiality. Patient Demographics Jonathan is a 63–year–old
man, born on August 23rd, 1956 and lives with his eldest son. He was married two times and has
three children, two children from his first marriage and one from his second. He lives in northern
Ontario but originally was from southern Ontario, he moved here shortly following his second
divorce. He is of Italian decent and is a practicing Catholic. The patient's weight is 95 kilograms; he
is 178 centimeters tall and has a body mass index (BMI) of 28.3. Jonathan says he smokes around
one pack of cigarettes a day, does not exercise enough and eats fast food a few times a week. The
patient now has congestive heart failure as a consequence of his myocardial infarction (MI) or heart
attack. He was transferred from another hospital in the beginning of November and was waiting for
more tests to be completed before he could be discharged. Jonathan has some known comorbidities
that can exacerbate his CHF, this includes smoking, obesity, and noncompliance with medications.
Congestive

Unstable Angina Case Study
Current Treatment and Consideration of Evidence Base: Upon admission, patient was most–likely
suspected of having ACS (acute coronary syndrome) because of CHD (coronary heart disease)
(NICE, 2014c). Troponin T High Sensitivity Test was carried out to distinguish whether chest pains
were because of NSTEMI or unstable angina (NICE, 2014b). This led to diagnosis of unstable
angina. His current treatment with regards to drug interactions is okay, except that enoxaparin has a
clinically significant interaction with aspirin (2015, p. 1199). This can be discounted for due to his
condition.
Patient has a CVD (cardiovascular disease); can be exacerbated by having high cholesterol (could be
the cause of his angina). Therefore, atorvastatin 80 mg was initiated for secondary prevention of CV
... Show more content on Helpwriting.net ...
Mention important benefits of quitting such as if patient quits smoking for 5 years or more, risk of
heart attack decreases by 50 to 70 percent (2012). Refer patient to NHS Stop smoking Service to
further help quitting. Emphasize important of exercise and diet on CVD progression. Explain how
active lifestyle reduces heart attack risk by 45% (2012). 2 hours and 30 minutes of moderate–
intensity aerobic activity every week is ideal, for example, walking fast or pushing a lawn mower
(NHS, 2014). Counsel patient on returning to normal day to day activities; ideal to wait 2 months
after CABG before doing strenuous activities (RCS, 2014). Emphasize importance of diet on CVD
progression. Mention important benefits such as that for every percent his serum cholesterol is
reduced, chance of having a heart attack is reduced by 2 percent. Patient should be counselled to
reduce salt intake to less than six grams a day, avoid caffeinated drinks, eat at least 5 portions of
fruits and vegetables a day, 2 portions of fish a week, and 4–5 portions of unsalted nuts, seed and
legumes per

The Question Being Posed?
The question being posed "Is there a benefit to having pharmacogenomics medical service in
community pharmacy?" The term pharmacogenomics and pharmacogenetics is frequently used
interchangeable, though there are subtle variances. Pharmacogenomics offers an opportunity to
individualize drug therapy in order to maximize efficacy and reduce toxicity according to the
patient's genetic data. In pharmacy practice, individualized drug therapy is regarded as an important
feature. Even when a drug is considered to be effective, thus the optimal dose would differ between
patients. 1
According to the Australian Law Reform Commission, pharmacogenomics is describes as "the
capacity to predict disease development and influence decisions about lifestyle choices or to tailor
medical practices to an individual"2. This concept of tailoring medicines is being progressively
introduced into Australia for each individual.2
As humans share 99.9 percentage of genetic sequence in a genome which allows pharmacogenomics
to use the difference of 0.1% between individuals. 3
Therefore, the focus of pharmacogenetics is genetic variations of genes, devoting to the concept of
"many genomes, one drug"3 indicating patient variability in order to achieve the desired product.3
This literature will mainly focus on the how innovative pharmacogenomics medical service is
implemented in community pharmacy and including the benefits of pharmacogenomics testing.
Section 2: Argument (1500 words)

Dual Antiplatelet Therapy Case
Case 3
Mrs JL is a 78 year old who is being discharged from your ward after being admitted following a
severe bout of gastroenteritis. She has made a full recovery and is about to be discharged. You took a
medication history from her when she was admitted and recorded that she was taking aspirin 100mg
daily and clopidogrel 75mg daily after having had a drug eluting stent inserted 6 months previously.
Her other admission medications include metformin 1g daily, perindopril 5mg daily. Mrs JL's
discharge script includes all the medications on admission except the clopidogrel. Is it Ok to cease
the clopidogrel in this patient?
A. Generate a PICO table and an answerable question for the given case
Patient/Population Elderly diabetic patient ... Show more content on Helpwriting.net ...
[7] However, diabetes still remains a major risk factor for restenosis after both bare–metal stents and
DESs. [10] Diabetes mellitus is regarded as a proinflammatory and prothrombotic condition, and
patients with diabetes mellitus are more frequently resistant to aspirin and clopidogrel than those
without diabetes mellitus. [2] The minimum necessary duration of DAPT may be longer in diabetic
than in nondiabetic patients. [2] Among diabetic patients, target vessel failure occurred more
frequently with 6–month DAPT than with 12–month DAPT. [2] Prolonged DAPT for >6 months
might be needed to prevent late stent thrombosis because of delayed vascular healing and
inflammatory reaction after implantation of drug–eluting stents.

Myocardial Infraction Report
Week #1 – Discussion #2 Rabitt, R. With a lifelong passion for the sciences, I became interested in
adult nurse practitioner cardiologist. Before pursing my education as NP, I lost two important people
in my life for heart disease, my father and my fifteen year old daughter. I realized that I enjoyed
making a difference in people's lives and empowering patients to be active participants in his/her
own healthcare through education and strong patient –healthcare provider relationship. I feel that I
can lead patient to achieving his/her health goals by provide support for the patient at the same time
focuses on myocardial infraction (MI) prevention through health promotion by emphasizing lifestyle
modifications to enhance overall quality of life.
I used the South ... Show more content on Helpwriting.net ...
The focuses in this article is "a diet rich in saturated fats and calories, smoking and sedentary life
plays an important role in the recurrence of coronary events in patients with diagnosed coronary
artery disease. In many people, this way of living leads to changes of biochemical and
pathophysiological characteristics, which increase the development of atherosclerosis and
thrombotic complications" (p.269). Consequently, dietary intervention and behavior changes play
significant role that can provide extra health benefit by improving or delay chronic diseases as well
as increase life expectancy and function of the body.
The third article "Cost–utility analysis of genotype–guided antiplatelet therapy in patients with
moderate–to high risk acute coronary syndrome and planned percutaneous coronary intervention" in
the Pharmacy Practice Journal, (2014). "The purpose of this study was to evaluate the cost–utility of
genotype–guided treatment, compared with prasugrel or generic clopidogrel treatment without
genotyping, from the US healthcare provider's perspective"

Causes Of Death Within Australia Is Cardiovascular Disease...
One of the most leading causes of death within Australia is cardiovascular disease with the aging
population being at an increased risk; within Australia 29.2% who are over the age of 75 will have
some type of cardiac disease (Australian Bureau of Statistics 2013). The aim of this essay is to use
the nursing process as a tool to work through an issue that may arise post angiogram to provide
appropriate plan of care, the issues that will be focused on throughout this paper is bleeding. This
paper will encompass a summary of the case Mrs. Green, the pathophysiology of a ST elevation
myocardial infarction, the patho–pharmacology of the medications that Mrs. Green is currently
taking, the mental health considerations that Mrs. Green may face, the ethical considerations that
need to be taken into consideration, the ANMC competencies 8.1 & 8.2 will be discussed, the
importance of patient outcomes will be analysed, a description of clinical reasoning will be
included, the plan of care will be discussed with a care plan added as an appendix and the inter–
professional roles will also be discussed. Mrs. Green is a 78 year old female who lives on her own in
a single story home in South Australia, (School of Nursing & Midwifery 2014). She is retired and is
a widow and has two children and 5 grandchildren, she has a very supportive family but they live a
while away and are only able to visit on the weekends, she has a pet dog named Matilda that keeps
her company (School of Nursing &

Clopidogrel Hypersensitivity is an Intricate Phenomenon
Presentation and Diagnosis Clopidogrel hypersensitivity is an intricate phenomenon. The reaction is
complex and has varied pathophysiology resulting in distinct onset and presentation.
Hypersensitivity may manifest as generalized, localized, or systemic reactions. Evidence suggests
that the majority of patients with hypersensitivity reactions will present with generalized, cutaneous
symptoms (6, 7). These generalized reactions may be an erythematous, maculopapular rash that is
pruritic or urticaria without mucosal involvement (6). Rashes are typically distributed throughout
the trunk and may involve upper and/or lower extremities (7, 8). Although less frequent than
generalized reactions, localized skin hypersensitivity has also been reported. (7). These reactions are
described as symmetrically appearing rashes localized to the face, palms, neck, axilla, soles of feet,
or back. (7). Finally, systemic hypersensitivity has been described. This may manifest as generalized
urticaria, fever, arthralgia, or angioedema (7–9). An evaluation of 24 patients with suspected
clopidogrel hypersensitivity described a median onset of hypersensitivity of 6 days (10). However,
the onset of these reactions varies and likely depends on type of hypersensitivity observed. A review
of 62 patients with clopidogrel hypersensitivity revealed a median onset of approximately 5 days for
both generalized and localized reactions compared to a median time to onset of 1 day for systemic
reactions (7).

Cats Case Study
Sixty cats were successfully enrolled during 18 months of the study period. Mean age of these cats
was 9.0 +/– 4.0 years old with 33 males and 27 females. The breeds of the cats enrolled include
Domestic short hair (21), Domestic long hair (14), Maine Coon (12), Ragdoll (4), Scottish Fold (4),
Persian (2), Himalayan (2), and Sphynx (1). Twenty–five of 60 cats (41.6%) had a known history of
HCM prior to the enrollment in this group. Echocardiographic examination prior to the enrollment
confirmed HCM in all enrolled cats with thickened left ventricular walls (interventricular septal wall
thickness during diastole: 7.1 +/– 0.4 mm, posterior wall thickness during diastole 6.9 +/– 0.5 mm)
and diastolic dysfunction. Thirteen cats of 60 cats ... Show more content on Helpwriting.net ...
The post–hoc analysis compared the mean rank of each genetic type with the mean rank of every
other genetic types. Percent inhibition of ADP–Ag in cats with mutated P2RY1 was significantly
lower than those with wildtype P2RY1 (P < 0.0001), mutated P2RY12 (P = 0.0036), wildtype
P2RY12 (P = 0.0126), and wildtype CYP2C19 genes (P = 0.0009). Percent inhibition of ADP–Ag in
cats with wildtype P2RY1 were significantly higher than mutated P2RY12 (P = 0.0406), wildtype
P2RY12 (P = 0.0123), and mutated CYP2C19 (P = 0.0061) (Figure 2).
There were also significant differences among groups with different genetic polymorphisms
(homozygous, heterozygous and wildtype) in P2RY1, P2RY12, and CYP2C19 genes (P < 0.0001).
The post–hoc analysis compared the mean rank of each polymorphism with the mean rank of every
other polymorphisms. Percent inhibition of ADP–Ag in cats with homozygous P2RY1 gene was
significantly lower than the cats with wildtype P2RY1 (P <0.0001), wildtype P2RY12 (P = 0.0064),
heterozygous P2RY12 (P = 0.0176), homozygous P2RY12 (P = 0.004), wildtype CYP2C19 (P =
0.001), and heterozygous CYP2C19 (P = 0.02). Percent inhibition in cats with heterozygous P2RY1
gene was also significantly lower than the cats with wildtype P2RY1 (P (–– removed HTML ––)
0.99). The comparisons of the percent inhibition in cats with different polymorphisms in P2RY12
and

The French Chemist Charles Frederic Gerhardt
In 1853, the French chemist Charles Frederic Gerhardt neutralized salicylic acid by insulating it
with sodium salicylate and acetyl chloride to make acetylsalicylic acid (Bellis, 2016). Gerhardt 's
item worked; however, he had no interest to sell it and deserted his revelation (Bellis, 2016). In
1899, a scientist by the name Felix Hoffmann, who worked for a German organization known as
Bayer, retrieved Gerhardt 's idea (Bellis, 2016). Felix Hoffmann made a portion of the formula and
offered it to his dad who was experiencing the torment of joint inflammation (Bellis, 2016). It
worked and Felix Hoffmann persuaded Bayer to showcase the new drug (Bellis, 2016). As a result,
aspirin medicine was licensed on February 27, 1900 (Bellis, 2016). The people at Bayer thought of
the name aspirin (Bellis, 2016). It originates from the "a" in acetyl chloride, the "spir" in spiraea
ulmaria (the plant they got the salicylic corrosive from) and the "in" was a well known name ending
for pharmaceuticals (Bellis, 2016). Thus, headache medicine was first sold as a powder (Bellis,
2016). In 1915, the primary aspirin pills were constructed (Bellis, 2016). To begin, aspirin has many
advantages for the body, as known today. College analysts, driven by Michael Garavito, Associate
Professor in Biochemistry and Molecular Biology, have found the exact synthetic system of aspirin
stops agony and aggravation (Scotsman, 1995). The group 's finding, reported in the diary
Nature/Structural Biology, implies

Primary Knee Arthritis
Inclusion criteria: 1) Primary knee Osteoarthritis with grade two and three of the Kellgren criteria,
2) Knee pain for at least 6 months, 3) Aged 65–45 years, 4) Primary Osteoarthritis (not caused by
other diseases such as Rheumatoid Arthritis and trauma), 5) signed consent. Exclusion criteria: 1)
Age above 65 years and less than 45 years, 2) Knee osteoarthritis with grade 0 and 1 and 4 the
criteria of the Kellgren criteria, 3) secondary osteoarthritis (due to trauma), 4) Knee arthroscopic
surgery in less than 6 months of the study, 5) Knee corticosteroids injection with less than 6 months
of the project or during of project, 6) Exist of other chronic inflammatory process, 7) History of
allergy to any of the compounds used in the study, 8) Patients with coagulation disorders and history
of coronary disease, 9) Patients treated with drugs that affect coagulation process: ... Show more
Curcumin is a very active compound and is responsible for the yellow color of turmeric which has
antioxidant and anti–inflammatory properties that can have a significant effect on osteoarthritis by
the protection of chondrocytes. The aim of this study was to evaluate the effectiveness of curcumin
in reducing the symptoms of patients with osteoarthritis of the knee. In this interventional study,
curcumin and placebo will be prescribed to the groups and a random number table will be used for
treatment allocation by the statistical analyzer. Patients and researchers will not know the group of
the patients and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) will be
completed for patients in 0 and 6 weeks of drug using. In this study, WOMAC questionnaire will be
completed for 80 patients (40 patients in curcumin group and 40 patients in the placebo group) with
knee osteoarthritis in 0 and 6

General Medicine Rotation Essay
6th Year General Medicine Rotation
Stephen Chiang 21209166@student.uwa.edu.au
Amlodipine
Information to patient: Indicated for hypertension and angina. Reduce the blood pressure and risk of
stroke and heart attack. They are calcium channel blockers which works by widening your blood
vessels making it easier for your heart to pump blood around the body and help increase blood and
oxygen supply to the heart. Taken once daily with or without food at the same time each day.
Swallow the tablet whole with a full glass of water. Taking the tablet at the same time each day will
have the best effect. It will also help you remember when to take it. You are currently on 5mg but
your doctor might increase this depending on how you respond to the medication. Tell your doctor
... Show more content on Helpwriting.net ...
Clopidogrel
Information to patient: Clopidogrel is an antiplatelet medication. Platelets are small blood cells that
clump together during blood clotting. Prevent clotting of platelet to prevent unwanted blood clots
after heart attack or stroke. Decreases risk of cardiovascular events but increases the risk of major
bleeding. Swallow the tablet with a glass of water. Taken with or without food as directed by doctor.
Taking the tablet at the same time each day has the best effect. It will also help you remember when
to take it. Avoid this medication if active bleeding present in GI tract. Do not stop clopidogrel
suddenly.
Side effect: bleeding, GI bleeding, diarrhoea and rash.
Safety and efficacy: Clopidogrel causes more recurrent ulcer bleeding. Combination of clopidogrel
and aspirin should not be used in patient with high risk of bleeding, recent TIA or stroke. Monitor
closely if interacting with other drugs can that affect the clotting process. Clopidogrel does not
require close blood test monitoring. Clopidogrel might interact with PPIs reducing its efficacy.
Consider changing this patient's PPI to a H2

Plavix Research Paper
Plavix (Clopidogrel)
The drug that will be discussed in this paper is Plavix. Plavix saves peoples veins and arteries from
clotting, so it saves people's lives every day. The pharmaceutical Drug Plavix is a blood thinner.
Blood thinners are used to prevent heart attacks most commonly. Plavix is a blood thinner, which
means it prevents the formation of blood clots in arteries, or veins. They do not get rid of existing
clots, but they prevent them from getting any bigger. When blood thinners are taken with a drug
called Aspirin, they prevent the platelets, or a type of blood cell, from sticking together and forming
clots. Taking Plavix with Aspirin can also relieve chest pain. Although Plavix can help prevent heart
attacks and blood clots, there ... Show more content on Helpwriting.net ...
The chemical formula is C16H16ClNO2SH2SO4 and its molecular weight is 419.9. The molar mass
for this drug is 321.82 g/mol. Normally, a person should take 300 mg, unless prescribed more or
less. Even though Plavix is usually taken in 300 mg. dosages, it is sold to many patients in 75 mg. as
well as 300 mg. tablets. The address of the manufacturer of Plavix is Bristol–Myers Squibb/Sanofi
Pharmaceuticals Partnership Bridgewater, NJ 08807. Plavix's website is
http://www.bms.com/pages/default.aspx. The manufacturers names are Bristol–Myers Squibb and
Sanofi Pharmacueticals. If someone is pregnant, there is no known risk if you take this drug. But, if
you drink alcohol and take this drug at the same time, there could be fatal consequences. Lastly,
even though it is called a blood thinner, it does not actually make your blood thinner. It just prevents
clots. In conclusion, Plavix is a drug that is also a blood thinner. It is taken by mouth and it reacts
with platelets. By reacting with these platelets, it prevents clots. But, there are some side effects,
some of which could be fatal. And lastly, you can buy this drug from Bristol–Myers Squibb and
Sanofi Pharmacueticals. That is why Plavix saves people's lives every

Pcp Case Studies
The client is a 51–year–old African American male who was cooperative during the assessment. The
client was given the diagnosis of Major Depressive Disorder, Mild while hospitalized during the
1980's. The client is unable to remember the name of the hospital. The client has been prescribed the
following medications: Clonidine Patch, Albuterol, Clarithromycin, Metformin, Loratadine,
Carafate, Hydralazine, Triamterene, Clopidogrel, Tartrate, Lisinopril, Atorvastatin, Buproban,
Pantoprazole, Amlodipine Besylate, Nitroglycerin, Lingual Spray. The client is seeing Dr. Johnson
as is PCP. Using a symptom checklist the client is currently experiencing the following several times
a week: sad moods, irritability, anger, moods swings, decreased energy

Armod (Armodafinil)
Uses Armod (Armodafinil) is a tablet form of Armodafinil containing 50mg per tablet. Armodafinil
is prescribed to treat people with ADHD (Attention–Deficit–Hyperactivity–Disorder) and sleep
disorders related to shift–work, as well as sleep apnea. The drug works elevates heart rate and blood
pressure, thereby promoting wakefulness. Dosage and Administration Armod (Armodafinil) is a
tablet that should be swallowed whole with a glass of water. It needs to be taken when the stomach
is full. It is crucial to consume lots of water and other fluids when taking Armodafinil. Dosage is
dependent on your condition and will be advised by your doctor. Generally, the recommended
dosage will be 50mg taken once daily in the morning. Even if symptoms disappear or reduce, make
sure ... Show more content on Helpwriting.net ...
Make sure to let your doctor know beforehand if you are breastfeeding since the drug is easily
passed in milk. If you are pregnant, the drug could cause further complications. Before taking
Armod (Armodafinil) you should advise your doctor if you have: Previous case of psychosis Mania
Renal or hepatic impairment Lactating or pregnant Armodafinil should not be taken by patients who
have cardiac arrhythmias or severe HTN. Patients with prolapsed of the mitral valve, or changes in
ischaemic ECG, as well as those with a previous record of hypertrophy of the left ventricle should
not take this medicine. Drug Interactions with Armodafinil: Celexa (citalopram) Clopidogrel Ibrance
(palbociclib) Lynparza (olaparib) Orlaam (Levomethadyl acetate) Palbociclib Plavix

Article Analysis : The Health Care Profession
Article Analysis The health care profession has dramatically changed over years in an attempt to
improve patients' outcome. For this reason, nurses have to be aware of rising health care issues as
well as evidence–based recommendations that can improve these problems. Rising health care
issues that are being explored include the advantage of pharmacological treatment based on
individuals' genetic makeup, the rise of urinary tract infections (UTIs), as well as recommendations
for preventing heart disease in women. The idea that human beings are as different to one another as
they are alike is not new and these differences are related to the genetic make–up of each individual.
Because all human beings are not identical, one can safely assume that medications that treat a
particular illness for one person can have a totally different effect on another. To support this theory,
the article What You Need To Know About Pharmacogenomics, written by Dennis Cheek discusses
a growing area of research known as pharmacogenomics where medications are being tailored based
on patient' genetic make–up. The main goal of pharmacogenomics is to help health care providers
improve patients' outcome with medications that are tailored to patients based on their genetic
make–up. The main areas of pharmacogenomics include antiplatelet therapy, mental health, HIV
therapy, and oncology (Cheek, 2013). Clopidogrel is a platelet Adenosine diphosphate (ADP)
receptor antagonist that has been researched

What Takeover Defenses Did Warner Use To Fend Off Pfizer
Question 2 2. What takeover defenses did Warner use to fend off Pfizer? What other defenses could
they have used?
Since the beginning of the agreement Warner Labs was aware that the partnership with Pfizer
represented the risk of an hostile takeover, because of this Warner carefully designed a defensive
agreement that allow the partnership, at the same time that avoiding somewhat the anticipated
movement and merge proposal.
The initial defense from warner should have come from the initial agreement, anticipating the Pfizer
proposal and leaving no room to Pfizer to legal actions or hostile proposals. In my view, the
standstill clause must have been reinforced by not allowing Pfizer any merge proposal even though,
the third party proposals

Myocardial Infarction Of An Acute Infarction
In the United Kingdom (UK) 69,163 individuals died of an Acute Myocardial Infarction (AMI) in
2014 (BHF 2015). 915,000 people are estimated to be living with a myocardial infarction (MI)
(BHF 2015). Studies from the Heart Research Institute UK (HRIUK) have also found that someone
dies in the (UK) every six minutes of an ST–segment elevation myocardial infarction (STEMI) and
that one in three passes away before reaching hospital About heart disease (Heart Research Institute
UK, 2010) Smoking, drinking alcohol to excess coupled with a diet of junk food and lack of
exercise all contribute to susceptibility of having an STEMI (WHO,2014). Research from the
Myocardial Infarction National Audit Project (MINAP) shows that there is over an 8% 30–day
mortality rate for patients admitted with a preliminary diagnosis of (STEMI) in the United Kingdom
(UK) (Gavalovar and Weston, 2014) In this critical reflection, I am going to discuss a case based on
a 70–year–old male who had suffered an acute STEMI. I will be critiquing our patient journey from
the first aspirin after our initial patient assessment through to thrombolysis if required onto PPCI,
with the 'gold standard' treatment for an STEMI being a PPCI (Andrew Whittaker, 2013). I will also
be discussing any new treatments available for paramedic practice in the future. The Health Care
and Profession Council (HCPC, 2014) states that a patient must first give consent for treatment,
effective communication is key in gaining this

Bristol Myers Squibb And Squibb Corporation
Bristol–Myers Squibb Company is the outcome of the merging of Bristol–Myers and Squibb
Corporation in 1989. Bristol–Myers Squibb is one of the world's largest pharmaceutical companies
head quartered in New York. BMS has global research facilities and manufacturing plants mainly in
the United States and Europe (Hoovers, 2015). The corporation has a unique set of strategic
principles that help built the company. The company divested in the nutritional and pharmaceutical
divisions. BMS expanded its strategies to become a biopharmaceutical leader. According to Hoovers
(2015), the company engaged in the String–of– Pearls pharmaceutical strategy that added barriers to
imitate biotech drugs and products within the company's pipeline. This company demonstrates
functional–level strategies that focuses on innovation and technology. BMS, the multi–business has
undergone issues associated with ethics, research, marketing and quality manufacturing. Therefore,
BMS strategies offers insight on the company struggles and operations.
Current Company Operations
Historical and Current Financial Aspects
Bristol–Myers Squibb was performing well financially until their major patent loss in 2012. The
company has been experiencing a fluctuation in revenues from 2009 through 2012. BMS current
stock price as of March 4, 2015 closed at $61.92 with a 52 week high of $64.44 and low of $46.30
(Hoovers, 2015). In 2013, the company announced its intentions to voluntarily delist its $2
Convertible Preferred

Org Behaviou
Table of Contents
1.0 Introduction 2
2.0 Initial Situation – Case Analysis 2
2.1 The History of Bristol–Myers Squibb (BMS) 2
2.2 Peter R. Dolan 3
2.3 What is Plavix? 3
2.4 Plavix Generic Drug Agreements 4
2.5 Dolan's Fate 5
3.0 Questions and Answers 6
3.1 Q1) What principles of distributive Negotiation did Sherman use to gain his advantage? 6
3.2 Q2 ) Do you think Sherman behaved ethically? Why or why not? 7
3.3 Q3) What does this incident tell you about the role of deception in negotiation? 9
4.0 Conclusion 10
1.0 Introduction
All organisations form an integral part of the global village. Therefore organisations have become
open systems due to deregulation, ever changing technology, lifestyle and demographics. In ... Show
Justice Department was investigating the company's March 2006 agreement with Canadian generic
drug manufacturer Apotex. The agreement was intended to delay the Apotex's release of an
inexpensive generic version of Plavix.
Under the terms of Bristol–Myers' ill–conceived agreement with Apotex, BMS offered Apotex $40
million to halt production of the generic Plavix until June 1, 2011. This date was five months before
the Plavix patent was set to expire. Bristol–Myers also agreed not to release its own non–branded
Plavix until six months after Apotex began to sell its generic version of the blood thinner. When
asked to approve the agreement, the U.S. Federal Trade Commission (FTC) and state Attorneys
General objected to these provisions. They labelled the Bristol–Myers concession anti–competitive
because it assured that Apotex would be the sole market vendor of cheap, generic Plavix for at least
six months. So, Bristol–Myers Squibb agreed to remove the anti–competitive provision from the
contract. Nevertheless, the FTC began questioning Apotex regarding the revised agreement. During
these questioning sessions, Apotex told the federal regulators that Bristol–Myers had given Apotex
private assurance that it would not release a general version of Plavix to the market.

Saddle Thrombus Research Paper
In most cases, if you were to tell a client that their cat has a paralysis inducing spinal cord disease
they would be rather confused. Let me break that down for you; paralysis is a loss of voluntary
movement in the animal. The spinal cord clearly has to do with the back, and a disease is something
that causes the body to not be one hundred percent healthy. Saddle Thrombus is a form of a paralysis
inducing spinal cord disease that is found in cats. Saddle thrombus can come on with no warning. It
causes them to be in extreme pain and will become paralyzed. Some symptoms of this disease are
crying, hiding and panting. Saddle thrombus is a blood clot that is in the middle of main arteries.
The pain itself can cause the pet to have heart

Essay On Polymorphisms
Using the whole genome sequence results of 9 cats, non–synonymous single nucleotide
polymorphisms (SNPs) in P2RY1, P2RY12, and CYP2C19 genes were identified (Table 2). Among
these SNPs, the p. P479L missense mutation in CYP2C19 gene on cat chromosome D3.56761959
caused by a cytosine–to–guanine (C>G) transversion has a high probability of altering protein
morphology and/or function predicted by PolyPhen2 with a damaging score of 0.997 (sensitivity:
0.41, specificity: 0.98). In addition, the p.A236G missense mutation in P2RY1 gene on cat
chromosome D2.110685284 caused by a guanine–to–cytosine (G>C) transversion had some
probability to cause functional modification of the P2Y1 ADP receptor predicted by PolyPhen2 with
a damaging score of 0.256 ... Show more content on Helpwriting.net ...
In humans, patients with the CYP2C19 variant are often classified as decreased responders to
clopidogrel and shows higher platelet activity and aggregation resulting in the higher risk of
developing thromboembolic events such as coronary artery infarction and stroke (Simon T et al.
NEJM 2009, Mega JL et al. Lancet 2010). In addition, one study has reported mutations in the
CYP2C19 gene as the key gene variant that influences the reactivity and pharmacodynamics of
clopidogrel in patients causing clopidogrel resistance (Price MJ et al. J Am Coll Cardiol 2012). In
the present study, cats with HCM frequently possess the p.P479L missense mutation in the
CYP2C19 gene which is predicted to cause low or no–response to clopidogrel therapy in cats. In
addition, the p.A236G mutation in the P2RY1 gene had some probability to cause function
modification of the P2Y1 ADP receptor, and each of the identified polymorphisms are seen in highly
conserved amino acids (Table 3). In human patients with cardiovascular disease, carriers of
mutations in P2Y12 gene had an increased risk for developing thromboembolic diseases (Ziegler S
et al. Stroke 2005). Although the p.V34I missense mutation in the P2RY12 gene was predicted to be
benign, it is still reasonable to further investigate this mutation in response to the effect on platelet
activity with clopdigorel administration in cats. Hypertrophic cardiomyopathy (HCM) is one of the
most common inherited cardiac disease in humans and

Essay On Clopidogrel
Clopidogrel is a second–generation thienopyridine antiplatelet agent used in humans and other
species including cats to reduce the risk of thromboembolic diseases secondary to cardiovascular
diseases and other systemic diseases. Once it's converted to clopidogrel active metabolite by
Cytochrome P450 isoenzymes, clopidogrel irreversibly inhibits one of the platelet ADP receptors
leading to an inhibition of platelet activation and aggregation. Several large clinical trials revealed
that clopidogrel administration in human patients significantly reduced the platelet activation and
aggregation in vivo, and decreased the frequency of developing thromboembolic events (Sabatine
MS et al. JAMA 2005, Yusuf S et al. NEJM 2001, Chen ZM et al. Lancet 2005). ... Show more
Approximately 15 – 30% of humans shows decreased efficacy of clopidogrel due to decreased
inhibition of ADP receptors, called clopidogrel resistance. Clopidogrel inhibits the purinergic ADP
receptor P2Y12, and genetic polymorphisms of this gene was reported to be associated with
clopidogrel resistance (Fontana P, et al. Circulation 2003, Ziegler S et al. Stroke 2005). Stimulation
of another ADP receptors on platelets, P2Y1, causes conformational change of platelet surface and
weak transient platelet aggregation. It has been speculated that mutations of P2Y1 increase function
of the P2Y1 receptor and allow an escape from P2Y12 blockage by clopidogrel and leads to
clopidogrel resistance (Kunapuli SP et al. Curr Opin Pharmacol 2003, Hetherington SL et al.
Thromb Vasc Biol, 2005). Loss–of–function variant alleles in the CYP2C19 gene in human patients
also have been investigated in associated with clopidogrel resistance, which has been identified
approximately 2–14% of people depending on the

A Potent Intravenous, Reversible, Inhibitor, And The...
Cangrelor, a potent intravenous, reversible, platelet P2Y12 inhibitor, was recently approved by both
the United States (U.S.) Food and Drug Administration (FDA) and the European Medicines Agency
(EMA) as an adjunct for percutaneous coronary intervention (PCI). The approval was based on
Cangrelor versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition
(CHAMPION) PHOENIX (1), a multi–center, double–dummy, double–blind trial, which
randomized 11,145 patients with stable angina, non–ST–segment elevation acute coronary
syndrome or ST–segment elevation myocardial infarction to receive cangrelor or clopidogrel at the
time of PCI.
CHAMPION PHOENIX (1) demonstrated that cangrelor significantly reduced the rate of ischemic
events without increasing severe bleeding. In the original analysis, bleeding was site–reported by the
blinded investigators according to pre–specified definitions and was not adjudicated. While the
EMA accepted this approach, during FDA review, the sponsor and the FDA independently re–
evaluated bleeding in a post hoc, non–blinded manner. This evaluation included potential bleeding
data not necessarily captured on the bleeding case report form (CRF) by the investigator, and
findings were categorized and interpreted according to jointly agreed criteria based on previously
published bleeding classifications. For example, there was a field in the CRF called "drop in
hemoglobin or hematocrit"; the review re–checked the laboratory dataset for

Proto Pump Inhibitors Essay
Description/Synopsis: Proton pump inhibitors (PPIs) are used for the treatment of gastroesophageal
reflux disease (GERD) and Laryngopharyngeal reflux (LPR) due to their potential to inhibit gastric
acid production. Unfortunately, high doses of PPIs are associated with adverse health outcomes. The
use of PPIs has been shown to affect the absorption of minerals and vitamin–like calcium, iron and
vitamin B12. Not only the risk of other severe conditions like hyperparathyroidism, diarrhea and
pneumonia increases upon the long–term use of PPIs but the negative effects also extend to coronary
heart disease and atherosclerotic diseases. PPIs reduce the efficacy of the drug clopidogrel which
inhibits platelet activation thereby contributing to coronary heart disease and myocardial ... Show
It is further reported to induce atrophic gastritis which can ultimately lead to gastric carcinoma.
Results of study: PPIs are generally considered safe, but initial studies reported that the short–term
use of this drug (8 months) was associated with adverse effects like vomiting/nausea, dizziness,
headache, and hypersensitivity reaction. On the basis of these observations, thereafter, several
studies unraveled potential long–term effects of PPI therapy. The studies reveal that upon intake of
PPIs calcium absorption efficiency decreases by 41% in elderly women. It is shown that odds ratio
for hip fracture increase with the intake of PPIs over subsequent years from 1.22 at one year, 1.41 at
two years, 1.54 at three years to 1.59 at four years. A significant difference in the value was seen
between men and women and the odds ratio was analyzed to be 1.78 vs 1.36, respectively. A study
further showed the increment in the odds ratio to 1.62 and 1.92 respectively upon the use of PPIs for
5 and 7 years, respectively. The OR for Vitamin B12 deficiency associated with the use of PPIs for
above a year was

Procedure For Laparoscopic Appendicectomy ( Emergency...
A 54–year–old man presents acutely with anterior NSTEMI and is treated with PCI (Drug eluting
stent) to the LAD and placed on DAPT (aspirin 300mg and ticagrelor 75 mg bd). He subsequently
develops abdominal pain, which is confirmed as acute appendicitis on CT scan and is referred by the
surgical unit for laparoscopic appendicectomy.
Discuss the timing of any surgery for this man generally, and more specifically with reference to the
pharmacology (kinetics and dynamics) of aspirin and ticagrelor. Include the advantages that
ticagrelor may have over clopidogrel in the management of percutaneous coronary intervention
(PCI) and acute coronary syndrome (ACS)?
Factors affecting surgical outcome:
1. Patient factors:
a. Middle aged man
b. Acute anterior NSTEMI, treated with PCI (Percutaneous Coronary Intervention with a Drug
Eluting Stent) to LAD
c. Subsequent acute abdominal pain (diagnosis of acute appendicitis confirmed by CT abdomen)
2. Surgical factors: For laparoscopic appendicectomy (emergency surgery).
3. Drug factors: On aspirin 300 mg and ticagrelor 75 mg bd.
When we think of the ideal time to operate on this patient, two facts leap to attention: first, it might
be unwise to proceed with surgery immediately as he has had a recent myocardial infarction, and
second, that the antiplatelets need to be managed optimally to get the best outcomes possible– there
is a fine line between the risk of stent thrombosis if they are stopped too early and excessive intra–
and

Tia Case Study
NURSING DIAGNOSIS Ineffective tissue perfusion / Altered cerebral tissue perfusion Risk for
injury: Stroke Impaired verbal communication r/t ischemic injury NURSING DIAGNOSIS
Ineffective tissue perfusion / Altered cerebral tissue perfusion Risk for injury: Stroke Impaired
verbal communication r/t ischemic injury NURSING INTERVENTIONS Careful monitoring of
neurological status (Glasgow come scale, LOC, pupillary responses, extremity movement and
strength, facial symmetry, speech and vital signs). Decrease in LOC may indicate increased ICP.
Tube feedings and IV fluids r/t dysphagia. F/C r/t incontinence, pt is placed on B&B training
program. Preventing contractures, building muscle tone with ROM activities, controlling ... Show
Other symptoms may include: tinnitus, vertigo, blurred vision, diplopia, eyelid ptosis and ataxia.
MANIFESTATIONS Contralateral weakness of the lower face, hands, arms and legs; transient
dysphasia; numbness or loss of sensation; headache; temporary loss of vision of one eye; sudden
inability to speak. Other symptoms may include: tinnitus, vertigo, blurred vision, diplopia, eyelid
ptosis and ataxia. ETIOLOGY Episode of cerebrovascular insufficiency with temporary episodes of
neurologic dysfunction lasting less than 24 hours and often less than 15 minutes. Most TIA
symptoms resolve within 3 hours. Symptoms lasting longer than 24 hours are classified as a stroke.
TIAs are thought to be caused by microemboli that temporarily occlude blood flow resulting in
ischemia of brain tissue. Often occurs in patients with carotid artery stenosis. ETIOLOGY Episode
of cerebrovascular insufficiency with temporary episodes of neurologic dysfunction lasting less than
24 hours and often less than 15 minutes. Most TIA symptoms resolve within 3 hours. Symptoms
lasting longer than 24 hours are classified as a stroke. TIAs are thought to be caused by microemboli
that temporarily

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