Different blood tests given for bleeding disorders or blood dyscrasiaTickendra Das
The document discusses blood dyscrasias, which are pathological conditions of the blood that usually involve disorders of the cellular elements of blood. Blood dyscrasia can refer to diseases where platelets, white blood cells, or red blood cells are too high or too low. Common blood dyscrasias include diseases that affect platelets like ITP and TTP, diseases that affect clotting factors like hemophilia and von Willebrand's disease, and diseases that affect red blood cells like sickle cell anemia. Tests used to diagnose blood dyscrasias include complete blood count, bleeding time, activated partial thromboplastin time, platelet aggregation test, and prothrombin time.
Approach to the adult with bleeding disorderAli S. Mayali
The normal clotting process involves platelets and coagulation factors working together to form a clot and stop bleeding. Platelets initially aggregate at the site of injury and release substances to enhance clotting. Coagulation factors are then activated through initiation and amplification pathways, leading to thrombin generation and fibrin strand formation to stabilize the clot. Bleeding disorders can occur if there are deficiencies or dysfunctions of platelets, coagulation factors, or excessive fibrinolysis. Laboratory tests including platelet count, bleeding time, prothrombin time, activated partial thromboplastin time, and thrombin time are used to evaluate the hemostatic system and identify the cause of bleeding disorders.
Key coagulation disorders covered in this document include hemophilia A caused by a factor VIII deficiency, hemophilia B from a factor IX deficiency, and von Willebrand disease where von Willebrand factor is defective
This document discusses various bleeding disorders including hemophilia, von Willebrand disease, and acquired bleeding disorders. It defines hemophilia as a rare genetic bleeding disorder caused by a deficiency in clotting factors such as VIII or IX. Von Willebrand disease is described as the most common inherited bleeding disorder caused by a defect in the von Willebrand factor. The document also outlines different types of acquired bleeding disorders and their causes, including deficiencies in clotting factors due to conditions like liver disease, vitamin K deficiency, or effects of anticoagulant drugs.
Bleeding, clotting,platelet disorder and it's managementRakhiYadav53
This document provides information on various bleeding, clotting, and platelet disorders and their nursing management. It discusses hemophilia, disseminated intravascular coagulation (DIC), hypoprothrombinemia, and idiopathic thrombocytopenic purpura. For each disorder, it covers definition, etiology, clinical manifestations, risk factors, diagnostic findings, medical management, complications, and nursing management. Hemophilia is defined as a hereditary coagulation disorder caused by a deficiency in clotting factor VIII or IX. DIC is an abnormal blood clotting response triggered by underlying diseases or conditions that causes clotting throughout the blood vessels. Nursing focuses on pain management, monitoring
Factor v deficiency is rare
first described in a Norwegian patient in 1943, Identified by Dr. Paul Owren .
Fewer than 200 cases of congenital factor V deficiency have been reported worldwide since 1943.
inheritance of factor V deficiency is autosomal recessive.
usually only needed for severe bleeds or before surgery.
there is no concentrate containing only factor V.
fresh plasma or (FFP) infusions are used to correct the deficiency temporarily and should be given daily during a bleeding episode.
Different blood tests given for bleeding disorders or blood dyscrasiaTickendra Das
The document discusses blood dyscrasias, which are pathological conditions of the blood that usually involve disorders of the cellular elements of blood. Blood dyscrasia can refer to diseases where platelets, white blood cells, or red blood cells are too high or too low. Common blood dyscrasias include diseases that affect platelets like ITP and TTP, diseases that affect clotting factors like hemophilia and von Willebrand's disease, and diseases that affect red blood cells like sickle cell anemia. Tests used to diagnose blood dyscrasias include complete blood count, bleeding time, activated partial thromboplastin time, platelet aggregation test, and prothrombin time.
Approach to the adult with bleeding disorderAli S. Mayali
The normal clotting process involves platelets and coagulation factors working together to form a clot and stop bleeding. Platelets initially aggregate at the site of injury and release substances to enhance clotting. Coagulation factors are then activated through initiation and amplification pathways, leading to thrombin generation and fibrin strand formation to stabilize the clot. Bleeding disorders can occur if there are deficiencies or dysfunctions of platelets, coagulation factors, or excessive fibrinolysis. Laboratory tests including platelet count, bleeding time, prothrombin time, activated partial thromboplastin time, and thrombin time are used to evaluate the hemostatic system and identify the cause of bleeding disorders.
Key coagulation disorders covered in this document include hemophilia A caused by a factor VIII deficiency, hemophilia B from a factor IX deficiency, and von Willebrand disease where von Willebrand factor is defective
This document discusses various bleeding disorders including hemophilia, von Willebrand disease, and acquired bleeding disorders. It defines hemophilia as a rare genetic bleeding disorder caused by a deficiency in clotting factors such as VIII or IX. Von Willebrand disease is described as the most common inherited bleeding disorder caused by a defect in the von Willebrand factor. The document also outlines different types of acquired bleeding disorders and their causes, including deficiencies in clotting factors due to conditions like liver disease, vitamin K deficiency, or effects of anticoagulant drugs.
Bleeding, clotting,platelet disorder and it's managementRakhiYadav53
This document provides information on various bleeding, clotting, and platelet disorders and their nursing management. It discusses hemophilia, disseminated intravascular coagulation (DIC), hypoprothrombinemia, and idiopathic thrombocytopenic purpura. For each disorder, it covers definition, etiology, clinical manifestations, risk factors, diagnostic findings, medical management, complications, and nursing management. Hemophilia is defined as a hereditary coagulation disorder caused by a deficiency in clotting factor VIII or IX. DIC is an abnormal blood clotting response triggered by underlying diseases or conditions that causes clotting throughout the blood vessels. Nursing focuses on pain management, monitoring
Factor v deficiency is rare
first described in a Norwegian patient in 1943, Identified by Dr. Paul Owren .
Fewer than 200 cases of congenital factor V deficiency have been reported worldwide since 1943.
inheritance of factor V deficiency is autosomal recessive.
usually only needed for severe bleeds or before surgery.
there is no concentrate containing only factor V.
fresh plasma or (FFP) infusions are used to correct the deficiency temporarily and should be given daily during a bleeding episode.
The Public Presentation does not include any confidential information or findings from this Team Masters Project with BioMarin Pharmaceutical.
BioMarin and KGI titled our project as:
"Recurrent bleeding in patients with mechanical flow devices: an environmental study."
The document discusses various coagulation disorders including:
1. Congenital coagulation disorders such as hemophilia A and B which are caused by deficiencies in coagulation factors VIII and IX.
2. Acquired coagulation disorders including disseminated intravascular coagulation (DIC), vitamin K deficiency, liver disease, and antibodies against coagulation factors.
3. The pathogenesis, clinical features, laboratory findings, and treatment of various coagulation disorders are explained.
Approach to a bleeding disorder: These presentation has the approach for a patient of bleeding disorder. it has History, physical finding, Investigations.
This document discusses bleeding disorders and provides details on specific disorders such as von Willebrand disease, hemophilia, and immune thrombocytopenia. It describes the pathophysiology of hemostasis and the coagulation cascade. Signs and symptoms of bleeding disorders are outlined depending on whether they affect the primary or secondary phase of hemostasis. The diagnostic approach and differential diagnosis for evaluating bleeding disorders is also summarized.
This document discusses common bleeding disorders in children. It covers bleeding disorders caused by defects in blood vessels, platelets, or coagulation factors. Specific disorders mentioned include hemophilia A/B, von Willebrand disease, immune thrombocytopenia, and platelet function disorders. Signs, symptoms, diagnosis, and management are described for each condition. The document provides an overview of evaluating children for bleeding disorders and differentiating between qualitative and quantitative platelet and coagulation factor defects.
Reversal of warfarin associated coagulopathy prothrombin complex concentratesTÀI LIỆU NGÀNH MAY
Để xem full tài liệu Xin vui long liên hệ page để được hỗ trợ
: https://www.facebook.com/thuvienluanvan01
HOẶC
https://www.facebook.com/garmentspace/
https://www.facebook.com/thuvienluanvan01
https://www.facebook.com/thuvienluanvan01
tai lieu tong hop, thu vien luan van, luan van tong hop, do an chuyen nganh
This document provides an overview of venous thrombo-embolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). It discusses the prevalence and impact of VTE, defining key terms like anticoagulants and thrombolytics. The presentation contents are outlined as covering the prevalence, diagnostic modalities and algorithm, and updates to the medical management of VTE. Diagnostic tests for VTE include ultrasound Doppler, D-dimer testing, and imaging studies like CT scans. Treatment involves anticoagulation or thrombolysis to prevent clots from growing or causing harm.
Demands for Haemophilia tratment centres to fullfull universal health access...SEJOJO PHAAROE
Haemophilia ia a rare disease that affect 1: 10 000 people. Demands for services, medication and access to cheap effective clotting factors is a human right for people living with haemophilia. A haemophilia registry is a demand from the Government at large .. Essential drug list should also contain haemophilia medication.
we need to be contacted for more information
www.thinktankent.com
This document summarizes a seminar presentation on approaches to bleeding disorders in pediatric patients. It provides an overview of homeostasis and the blood clotting process, as well as some common bleeding disorders seen in pediatrics. The diagnosis of bleeding disorders involves taking a medical history, performing a physical exam, and conducting laboratory investigations such as platelet count, bleeding time, prothrombin time, activated partial thromboplastin time, and thrombin time to evaluate the platelet count and function, as well as factors in the intrinsic and extrinsic coagulation pathways.
The document provides guidelines for diagnosing and managing disseminated intravascular coagulation (DIC). It states that DIC diagnosis requires both clinical and laboratory information. The International Society for Thrombosis and Haemostasis scoring system objectively measures DIC and correlates with clinical outcomes. The cornerstone of DIC treatment is treating the underlying condition. Transfusions are generally reserved for bleeding patients, though platelets may be considered for patients with platelet counts under 50 · 109/l who are at high risk of bleeding or will undergo an invasive procedure.
This document discusses various bleeding disorders including:
1. Disorders of primary haemostasis including vessel wall abnormalities like hereditary haemorrhagic telangiectasia and scurvy, as well as platelet function disorders and thrombocytopenia.
2. Coagulation disorders including haemophilia A, haemophilia B, von Willebrand disease, and acquired bleeding disorders.
3. Specific details are provided on hereditary haemorrhagic telangiectasia, scurvy, idiopathic thrombocytopenic purpura, haemophilia A, haemophilia B, and von Willebrand disease. Management strategies are discussed for treating bleeding episodes in these
Hemophilia A is the most common form of hemophilia, caused by reduced levels or activity of coagulation factor VIII. This leads to prolonged and unstable clot formation when bleeding occurs. Symptoms can range from bleeding after circumcision or venipuncture in infants to spontaneous bleeding in joints in older patients. Diagnosis involves tests that show prolonged activated partial thromboplastin time and low factor VIII levels. Treatment replaces the missing clotting factor, with severity and location of bleeding determining dosage. Preventative treatment and education on self-administered factor replacement can help manage symptoms.
This document discusses hemostasis and various bleeding disorders. It defines hemostasis and describes the primary and secondary stages. The primary stage involves platelet plug formation from platelet adhesion, activation, and aggregation. The secondary stage activates the intrinsic and extrinsic coagulation pathways. The document outlines various signs and symptoms of bleeding disorders and provides examples. It discusses screening tests like complete blood count, prothrombin time, activated partial thromboplastin time, and bleeding time. Finally, it analyzes several case scenarios involving abnormal coagulation test results.
Bleeding disorders are genetic disorders characterized by prolonged or increased bleeding due to abnormalities in the blood's ability to clot. They result from decreased levels or function of one of the eleven clotting factors involved in clot formation. The three stages of normal clotting are vessel constriction, platelet plug formation, and fibrin clot formation. In bleeding disorders, the first two stages function normally but a mature fibrin clot does not form due to the missing clotting factor, leading to repeated bleeding and clotting. The most common types are hemophilia A and B which result from factor VIII and IX deficiencies. A detailed patient history, especially of abnormal bleeding in male family members, is important for diagnosis
This document discusses various factors that can lead to intravascular thrombosis, known as the Virchow triad of endothelial injury, abnormal blood flow, and hypercoagulability. It focuses on how endothelial injury and activation from physical or chemical insults can promote a prothrombotic state. Abnormal blood flow from turbulence or stasis is also prothrombotic by damaging endothelium and allowing platelets to adhere. Hypercoagulability can be inherited through gene mutations or acquired through conditions, medications, cancers, or age. Specific acquired hypercoagulable states of concern are heparin-induced thrombocytopenia and anti-phospholipid antibody syndrome.
This document provides an overview of approach to bleeding and evaluation of bleeding disorders. It discusses the basics of hemostasis including platelets and clotting factors. Common bleeding disorders like thrombocytopenia, hemophilia, and von Willebrand disease are described. The evaluation of bleeding disorders includes history, physical exam, and screening laboratory tests. Specific coagulation factor deficiencies, liver disease, disseminated intravascular coagulation, and acquired coagulation factor inhibitors are also reviewed. Treatment focuses on supporting hemostasis and addressing underlying causes.
Hemophilia is a group of inherited bleeding disorders caused by deficiencies in clotting factors VIII or IX. The main types are hemophilia A (factor VIII deficiency) and hemophilia B (factor IX deficiency). Symptoms include prolonged bleeding from minor injuries, excessive bruising, and bleeding into joints and muscles. Treatment involves replacing the missing clotting factor through infusions of factor concentrates. Nursing care focuses on preventing and controlling bleeding episodes, limiting joint damage, managing pain, providing education and emotional support to patients and families, and ensuring proper long-term home management of the condition.
Von Willebrand disease (VWD) is the most common inherited bleeding disorder, caused by mutations resulting in decreased or impaired von Willebrand factor (VWF). VWF promotes clotting by forming bridges between platelets and injured endothelium, and between platelets. It also carries and protects factor VIII. VWD is classified into three main types - type I is most common due to VWF deficiency; type II involves functional defects; type III is most severe with very low VWF. Treatment involves desmopressin, VWF replacement, or factor VIII depending on type and severity of bleeding. Careful management is needed around surgery, delivery, and circumcision.
Hemophilia is a genetic bleeding disorder caused by deficiencies in coagulation factors VIII or IX. It affects males primarily and can range from mild to severe. The main types are hemophilia A (factor VIII deficiency) and hemophilia B (factor IX deficiency). Treatment involves replacing the missing clotting factor through prophylactic or on-demand regimens to prevent or treat bleeding episodes. Complications can include hemarthrosis, joint damage, fractures, and pseudotumors, so treatment seeks to maintain adequate factor levels and address medical issues promptly. Proper diagnosis and laboratory testing are needed to determine severity and guide personalized management.
1.Assess the main steps involved in developing an effective stra.docxKiyokoSlagleis
1.
Assess the main steps involved in developing an effective strategic plan. Discuss how the steps may differ for a health care organization compared to another industry.
2.
Evaluate the key factors involved in SHEEPED (socioeconomic factors, health care resources and utilization, epidemiological factors, economic factors, political factors, environmental factors, and demographic factors) and their important role in strategic planning. Discuss why it is important for one to consider and include each factor.
.
1.Choose one of the critical steps to building a secure organi.docxKiyokoSlagleis
1.
Choose one of the critical steps to building a secure organization. In 350- to 700-words, explain how and why this step is used in an organization to protect information assets.
2.
In 350- to 700-words, discuss the challenges that leaders and security professionals encounter when trying to balance policy, training, and technology to secure organization information systems.
APA Formatting
Please provide three scholarly references.
.
The Public Presentation does not include any confidential information or findings from this Team Masters Project with BioMarin Pharmaceutical.
BioMarin and KGI titled our project as:
"Recurrent bleeding in patients with mechanical flow devices: an environmental study."
The document discusses various coagulation disorders including:
1. Congenital coagulation disorders such as hemophilia A and B which are caused by deficiencies in coagulation factors VIII and IX.
2. Acquired coagulation disorders including disseminated intravascular coagulation (DIC), vitamin K deficiency, liver disease, and antibodies against coagulation factors.
3. The pathogenesis, clinical features, laboratory findings, and treatment of various coagulation disorders are explained.
Approach to a bleeding disorder: These presentation has the approach for a patient of bleeding disorder. it has History, physical finding, Investigations.
This document discusses bleeding disorders and provides details on specific disorders such as von Willebrand disease, hemophilia, and immune thrombocytopenia. It describes the pathophysiology of hemostasis and the coagulation cascade. Signs and symptoms of bleeding disorders are outlined depending on whether they affect the primary or secondary phase of hemostasis. The diagnostic approach and differential diagnosis for evaluating bleeding disorders is also summarized.
This document discusses common bleeding disorders in children. It covers bleeding disorders caused by defects in blood vessels, platelets, or coagulation factors. Specific disorders mentioned include hemophilia A/B, von Willebrand disease, immune thrombocytopenia, and platelet function disorders. Signs, symptoms, diagnosis, and management are described for each condition. The document provides an overview of evaluating children for bleeding disorders and differentiating between qualitative and quantitative platelet and coagulation factor defects.
Reversal of warfarin associated coagulopathy prothrombin complex concentratesTÀI LIỆU NGÀNH MAY
Để xem full tài liệu Xin vui long liên hệ page để được hỗ trợ
: https://www.facebook.com/thuvienluanvan01
HOẶC
https://www.facebook.com/garmentspace/
https://www.facebook.com/thuvienluanvan01
https://www.facebook.com/thuvienluanvan01
tai lieu tong hop, thu vien luan van, luan van tong hop, do an chuyen nganh
This document provides an overview of venous thrombo-embolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). It discusses the prevalence and impact of VTE, defining key terms like anticoagulants and thrombolytics. The presentation contents are outlined as covering the prevalence, diagnostic modalities and algorithm, and updates to the medical management of VTE. Diagnostic tests for VTE include ultrasound Doppler, D-dimer testing, and imaging studies like CT scans. Treatment involves anticoagulation or thrombolysis to prevent clots from growing or causing harm.
Demands for Haemophilia tratment centres to fullfull universal health access...SEJOJO PHAAROE
Haemophilia ia a rare disease that affect 1: 10 000 people. Demands for services, medication and access to cheap effective clotting factors is a human right for people living with haemophilia. A haemophilia registry is a demand from the Government at large .. Essential drug list should also contain haemophilia medication.
we need to be contacted for more information
www.thinktankent.com
This document summarizes a seminar presentation on approaches to bleeding disorders in pediatric patients. It provides an overview of homeostasis and the blood clotting process, as well as some common bleeding disorders seen in pediatrics. The diagnosis of bleeding disorders involves taking a medical history, performing a physical exam, and conducting laboratory investigations such as platelet count, bleeding time, prothrombin time, activated partial thromboplastin time, and thrombin time to evaluate the platelet count and function, as well as factors in the intrinsic and extrinsic coagulation pathways.
The document provides guidelines for diagnosing and managing disseminated intravascular coagulation (DIC). It states that DIC diagnosis requires both clinical and laboratory information. The International Society for Thrombosis and Haemostasis scoring system objectively measures DIC and correlates with clinical outcomes. The cornerstone of DIC treatment is treating the underlying condition. Transfusions are generally reserved for bleeding patients, though platelets may be considered for patients with platelet counts under 50 · 109/l who are at high risk of bleeding or will undergo an invasive procedure.
This document discusses various bleeding disorders including:
1. Disorders of primary haemostasis including vessel wall abnormalities like hereditary haemorrhagic telangiectasia and scurvy, as well as platelet function disorders and thrombocytopenia.
2. Coagulation disorders including haemophilia A, haemophilia B, von Willebrand disease, and acquired bleeding disorders.
3. Specific details are provided on hereditary haemorrhagic telangiectasia, scurvy, idiopathic thrombocytopenic purpura, haemophilia A, haemophilia B, and von Willebrand disease. Management strategies are discussed for treating bleeding episodes in these
Hemophilia A is the most common form of hemophilia, caused by reduced levels or activity of coagulation factor VIII. This leads to prolonged and unstable clot formation when bleeding occurs. Symptoms can range from bleeding after circumcision or venipuncture in infants to spontaneous bleeding in joints in older patients. Diagnosis involves tests that show prolonged activated partial thromboplastin time and low factor VIII levels. Treatment replaces the missing clotting factor, with severity and location of bleeding determining dosage. Preventative treatment and education on self-administered factor replacement can help manage symptoms.
This document discusses hemostasis and various bleeding disorders. It defines hemostasis and describes the primary and secondary stages. The primary stage involves platelet plug formation from platelet adhesion, activation, and aggregation. The secondary stage activates the intrinsic and extrinsic coagulation pathways. The document outlines various signs and symptoms of bleeding disorders and provides examples. It discusses screening tests like complete blood count, prothrombin time, activated partial thromboplastin time, and bleeding time. Finally, it analyzes several case scenarios involving abnormal coagulation test results.
Bleeding disorders are genetic disorders characterized by prolonged or increased bleeding due to abnormalities in the blood's ability to clot. They result from decreased levels or function of one of the eleven clotting factors involved in clot formation. The three stages of normal clotting are vessel constriction, platelet plug formation, and fibrin clot formation. In bleeding disorders, the first two stages function normally but a mature fibrin clot does not form due to the missing clotting factor, leading to repeated bleeding and clotting. The most common types are hemophilia A and B which result from factor VIII and IX deficiencies. A detailed patient history, especially of abnormal bleeding in male family members, is important for diagnosis
This document discusses various factors that can lead to intravascular thrombosis, known as the Virchow triad of endothelial injury, abnormal blood flow, and hypercoagulability. It focuses on how endothelial injury and activation from physical or chemical insults can promote a prothrombotic state. Abnormal blood flow from turbulence or stasis is also prothrombotic by damaging endothelium and allowing platelets to adhere. Hypercoagulability can be inherited through gene mutations or acquired through conditions, medications, cancers, or age. Specific acquired hypercoagulable states of concern are heparin-induced thrombocytopenia and anti-phospholipid antibody syndrome.
This document provides an overview of approach to bleeding and evaluation of bleeding disorders. It discusses the basics of hemostasis including platelets and clotting factors. Common bleeding disorders like thrombocytopenia, hemophilia, and von Willebrand disease are described. The evaluation of bleeding disorders includes history, physical exam, and screening laboratory tests. Specific coagulation factor deficiencies, liver disease, disseminated intravascular coagulation, and acquired coagulation factor inhibitors are also reviewed. Treatment focuses on supporting hemostasis and addressing underlying causes.
Hemophilia is a group of inherited bleeding disorders caused by deficiencies in clotting factors VIII or IX. The main types are hemophilia A (factor VIII deficiency) and hemophilia B (factor IX deficiency). Symptoms include prolonged bleeding from minor injuries, excessive bruising, and bleeding into joints and muscles. Treatment involves replacing the missing clotting factor through infusions of factor concentrates. Nursing care focuses on preventing and controlling bleeding episodes, limiting joint damage, managing pain, providing education and emotional support to patients and families, and ensuring proper long-term home management of the condition.
Von Willebrand disease (VWD) is the most common inherited bleeding disorder, caused by mutations resulting in decreased or impaired von Willebrand factor (VWF). VWF promotes clotting by forming bridges between platelets and injured endothelium, and between platelets. It also carries and protects factor VIII. VWD is classified into three main types - type I is most common due to VWF deficiency; type II involves functional defects; type III is most severe with very low VWF. Treatment involves desmopressin, VWF replacement, or factor VIII depending on type and severity of bleeding. Careful management is needed around surgery, delivery, and circumcision.
Hemophilia is a genetic bleeding disorder caused by deficiencies in coagulation factors VIII or IX. It affects males primarily and can range from mild to severe. The main types are hemophilia A (factor VIII deficiency) and hemophilia B (factor IX deficiency). Treatment involves replacing the missing clotting factor through prophylactic or on-demand regimens to prevent or treat bleeding episodes. Complications can include hemarthrosis, joint damage, fractures, and pseudotumors, so treatment seeks to maintain adequate factor levels and address medical issues promptly. Proper diagnosis and laboratory testing are needed to determine severity and guide personalized management.
1.Assess the main steps involved in developing an effective stra.docxKiyokoSlagleis
1.
Assess the main steps involved in developing an effective strategic plan. Discuss how the steps may differ for a health care organization compared to another industry.
2.
Evaluate the key factors involved in SHEEPED (socioeconomic factors, health care resources and utilization, epidemiological factors, economic factors, political factors, environmental factors, and demographic factors) and their important role in strategic planning. Discuss why it is important for one to consider and include each factor.
.
1.Choose one of the critical steps to building a secure organi.docxKiyokoSlagleis
1.
Choose one of the critical steps to building a secure organization. In 350- to 700-words, explain how and why this step is used in an organization to protect information assets.
2.
In 350- to 700-words, discuss the challenges that leaders and security professionals encounter when trying to balance policy, training, and technology to secure organization information systems.
APA Formatting
Please provide three scholarly references.
.
1.Briefly summarize the purpose of the implementation phase in SDLC..docxKiyokoSlagleis
1.Briefly summarize the purpose of the implementation phase in SDLC. Explain why it exists and what it contributes to the completion of the system.
3.Explain the role and interests of the project champion, organizational management, and end users regarding a new system project. How will each impact the organizational feasibility of the project?
4.What are the three fundamental analysis strategies? Compare and contrast the outcomes of each strategy.
5.What are the four types of use cases? When are each used?
6.Requirements’ gathering is an important phase in a project. Discuss requirements gathering techniques and some advantages and disadvantages of each.
7.Define “scope creep” and discuss how a project manager can avoid it.
9.Describe the following object-oriented programming terms:
Encapsulation
Inheritance
Polymorphism
.
1.Choose four standard corporate executive positions and des.docxKiyokoSlagleis
1.
Choose
four standard corporate executive positions and
describe
their roles on the IT Steering Committee.
2.
Explain the relationship
between the IT architecture and the IT Roadmap used in the IT Strategic Plan.
3.
Different kinds of personnel are required to staff an IT department depending on their IT strategy.
For the two organizations below
, identify four IT positions
that are most important in each organization and
why
.
a.
An organization whose IT strategy is to outsource as much of their IT as possible, and
b.
An organization whose IT strategy is to develop proprietary, in-house applications that directly support their business and operation.
4.
Explain
what business continuity planning is,
who should create the plan
, and the
role of IT
.
5.
Explain what it means to say that the “IT Strategic Plan is aligned to the business Strategic Plan”.
6.
Explain risk management
and
what it
means to the CIO.
7.
Give an example
of a tangible (quantifiable)
and
an intangible (qualitative) performance measure and
discuss the value of each
.
8.
The CIO is responsible for the business rules or requirements that generate a new system or changes to the existing system.
How is his/her role responsible for these changes
?
9.
What is change management and how does it relate to the IT organization?
.
1.An eassy talk about ethics by a ethics song. You can find a ethics.docxKiyokoSlagleis
1.An eassy talk about ethics by a ethics song. You can find a ethics song on youtube
2.
but please think deeply about meaning. I have attached an example. Notice that I used specific words to describe fairness in justice. You will recieve less than two points if you do not comprehend and use correctly words such as proportional fairness. doc
.
1.A school psychologist strongly believes a particular child is .docxKiyokoSlagleis
1.
A school psychologist strongly believes a particular child is in need of special services. What is the psychologist trying to control for if he or she uses the most recently normed test available?
2.
What are two benefits of the WASI?
3.
Identify three improvements of the WAIS-IV over the WAIS-III.
4.
Provide one advantage and one disadvantage of group-administered intelligence tests.
5.
Give three examples of extra-test behavior on an ability test.
6.
Name three recommended uses for the Woodcock-Johnson III.
7.
Name three things that would be included in the best approach to diagnosing a specific learning ability.
8.
What is the purpose of empirical criterion keying?
9.
Identify two functions of validity scales on personality tests.
10.
Identify a criticism of the MMPI that contributed to the need for developing the MMPI-2. Identify a criticism of the MMPI-2.What is the purpose of the inquiry stage of the administration of the Rorschach test?
11.
What is the purpose of the inquiry stage of the administration of the Rorschach test?
12.
Identify three criticisms of projective tests.
13.
What principle do assessors utilize when interpreting the TAT?
14.
Give an example of a behavioral assessment approach.
15.
What does a mental status exam assess?
16.
Give an example of the Barnum effect.
17.
Why is it recommended to utilize the BDI-II with other tests?
18.
What are three things that the Tower of Hanoi measures?
19.
Give an example of a performance assessment.
20.
What is an assessment center and what is it utilized for?
Essay Questions
The essay questions below are worth 10 points each.
1.
Compare and contrast two established personality assessments discussed in the course. Include in your discussion strengths and limitations of each measure.
2.
Throughout the course, issues related to cultural diversity have been addressed. Identify one intelligence, educational, or personality measure and describe its strengths and weaknesses as it relates to diversity.
3.
Identify and describe at least three ethical dilemmas or responsibilities a psychological assessor may face.
.
1.Choose one stanza from Aaron Abeytas thirteen ways of looking .docxKiyokoSlagleis
1.
Choose one stanza from Aaron Abeyta's "thirteen ways of looking at a tortilla", and explain how it parodies another poem. What do you notice about this particular stanza. What makes it humorous, or witty, or ambiguous, insightful, etc. (Note, just choose one stanza, not the whole poem.)
2.
Choose one poem from Chapter 14 that you identify with, or seem to have a connection to. Why do you like this poem? Explain in depth what you like or identify with, and include textual evidence from the poem.
3.
Your textbook authors put the terms
translation
and
parody
together in the same chapter (Chapter 15). Why do you think this is? What are the connections between translation and parody? How do they relate to each other?
the material is the peom from chapter 14
.
1.A psychologist is interested in learning more about how childr.docxKiyokoSlagleis
A psychologist wants to understand how children interact when unobserved during school. Observational research would allow the psychologist to directly see children's unwatched behavior, but it risks invading their privacy without consent. Gaining permission and ensuring anonymity would help address ethical concerns in observational research of children.
1.A school psychologist strongly believes a particular child i.docxKiyokoSlagleis
1.
A school psychologist strongly believes a particular child is in need of special services. What is the psychologist trying to control for if he or she uses the most recently normed test available?
2.
What are two benefits of the WASI?
3.
Identify three improvements of the WAIS-IV over the WAIS-III.
4.
Provide one advantage and one disadvantage of group-administered intelligence tests.
5.
Give three examples of extra-test behavior on an ability test.
6.
Name three recommended uses for the Woodcock-Johnson III.
7.
Name three things that would be included in the best approach to diagnosing a specific learning ability.
8.
What is the purpose of empirical criterion keying?
9.
Identify two functions of validity scales on personality tests.
10.
Identify a criticism of the MMPI that contributed to the need for developing the MMPI-2. Identify a criticism of the MMPI-2.What is the purpose of the inquiry stage of the administration of the Rorschach test?
11.
What is the purpose of the inquiry stage of the administration of the Rorschach test?
12.
Identify three criticisms of projective tests.
13.
What principle do assessors utilize when interpreting the TAT?
14.
Give an example of a behavioral assessment approach.
15.
What does a mental status exam assess?
16.
Give an example of the Barnum effect.
17.
Why is it recommended to utilize the BDI-II with other tests?
18.
What are three things that the Tower of Hanoi measures?
19.
Give an example of a performance assessment.
20.
What is an assessment center and what is it utilized for?
Essay Questions
The essay questions below are worth 10 points each.
1.
Compare and contrast two established personality assessments discussed in the course. Include in your discussion strengths and limitations of each measure.
2.
Throughout the course, issues related to cultural diversity have been addressed. Identify one intelligence, educational, or personality measure and describe its strengths and weaknesses as it relates to diversity.
3.
Identify and describe at least three ethical dilemmas or responsibilities a psychological assessor may face.
.
1.According to the NIST, what were the reasons for the collapse of.docxKiyokoSlagleis
1.
According to the NIST, what were the reasons for the collapse of the Twin Towers on September 11, 2001? List and explain a minimum of four of the reasons given in the NIST report.
Your response should be at least 200 words in length. You are required to use at least your textbook as source material for your response. All sources used, including the textbook, must be referenced; paraphrased and quoted material must have accompanying citations.
2.
Discuss the various collapse types and the indicators that firefighters must be aware of while operating on scene of an emergency. Include the dangers associated with each type of building construction and the importance of collapse zones during response and mitigation efforts.
Your response should be at least 200 words in length. You are required to use at least your textbook as source material for your response. All sources used, including the textbook, must be referenced; paraphrased and quoted material must have accompanying citations
.
1.5 page for thisPlease review the Case Study introduction present.docxKiyokoSlagleis
1.5 page for this
Please review the Case Study introduction presented below...and provide a one to two page input on your thoughts relative this event. Please submit your input as a word document format (.doc). Please remember to cite the sources for your research.
Case Study - "Hubble Trouble":
Some years ago work began on the development of the Hubble Space Telescope....which was placed into low earth orbit in 1990.
The capability provided by the Hubble Space Telescope is a historic prescedent for mankind.....vis a vis the advanced imaging of the cosmos.....from a vantage point in space....free from image distortion caused by the earth's atmosphere.
Considerable care and planning was associated with the development of this complex space based instrument.
Unfortunately, the Hubble Space Telescope experienced several delays and cost over-runs.
The deployment of the Hubble Space Telescope was further delayed due to the un-related loss of the Space Shuttle Challenger.
Once the Hubble Space Telescope was ultimately deployed it was discovered that the telescope suffered from a significant optics error in the development of it's primary reflecting mirror.
Fortunately, a team was able to develop a solution to address this error....at considerable additional expense....and opportunity loss (vis a vis...the re-allocation of space shuttle missions to implement the solution....).
Questions:
What went wrong in the development of the Hubble Space Telescope ?
What was the impact / consequences associated with this error ?
What actions did the Hubble Space Telescope development team employ to preclude the problem from happening ?
Why weren't the actions that the team employed sufficient to prevent this embarassing problem from occuring ?
What Systems Engineering processes / actions should the James Webb Space Telescope development team consider employing to preclude such a problem from occuring in this successor space telescope ?
1.5 pagr for sumurry and
use the calculations in your summary for case study in fracture
.
1.) What is Mills response to the objection that happiness cannot b.docxKiyokoSlagleis
1.) What is Mill's response to the objection that happiness cannot be the rational purpose of life?
2.) What is Mill's view on "all the grand sources…of human suffering?"
3.) What is Mill's view of self-sacrifice?
4.) Why would someone object that the disinterested character and promotion of general welfare that utilitarianism demands is unreasonable to expect?
5.) What is Mill's response to the objection that the disinterested character and promotion of general welfare that utilitarianism demands is unreasonable to expect?
6.) Explain the objection that utilitarianism renders men cold and unsympathizing. What is Mill's reponse?
7.) Explain the objection that utilitarianism is a doctrine of expediency. What is Mill's response?
8.) Why would someone object that utilitarianism is flawed because there is not time to calculate consequences?
.
1.Add an example or evidence for each reasons ( i listd )why the use.docxKiyokoSlagleis
1.Add an example or evidence for each reasons ( i listd )why the use of animals in research is good ,and also add a example or evidence for that is not good .And write more sentences to make it persuasively for the thesis.(explain why is imortant to society)
2.Change the APA style to MLA style.
3.Add more sentences in conclusion
.
1.1. Some of the most serious abuses taking place in developing .docxKiyokoSlagleis
1.
1. Some of the most serious abuses taking place in developing countries deal with child labor, human slavery, sweatshops, bad governance, and environmental degradation. Select one (1) developing country, and examine the extent to which two (2) of these five (5) issues are occurring. Support your response with specific examples.
2.
2.
Select one (1) developing country, and discuss the fundamental actions that the leadership of the selected country is — or is not — taking to improve the living standards of its people. Next, using this same country, cite one (1) specific example of progress or regress that its government is making in terms of the economy, the political system, and the environment.
.
1.A population of grasshoppers in the Kansas prairie has two col.docxKiyokoSlagleis
1.
A population of grasshoppers in the Kansas prairie has two color phenotypes, green and brown. Typically, the prairie receives adequate water to maintain healthy, green grass. Assume a bird that eats grasshoppers moves into the prairie. How will this affect natural selection of the grasshoppers? How might this change in a drought year?
2.
You are a writer for “Consumer Reports” magazine and you are asked to design an experiment to evaluate the effectiveness of three brands of whitening strips for teeth.
Describe how you would do this using the Scientific Method. Include all of the steps, controls and variables.
3.
Viruses are not considered to be living organisms.
Name 4 characteristics you could identify to distinguish living organisms from viruses.
4.
Explain the process of cell division in animals.
Include a description of
interphase, mitosis and cytokinesis.
5.
Suppose someone presented data from their research that showed the DNA of a newly discovered species was composed of: 30% adenine, 30% guanine, 20% thymine, 20% cytosine. Based on what you know about DNA structure, explain why these data do not make sense.
6.
What are the differences between a covalent bond and an ionic bond?
7
.
Water is crucial for life as we know it. One of the most important characteristics of water is its ability to act as a solvent.
Explain why water is such a good solvent for polar and charged molecules.
8.
Suppose you are taking a cruise from California to Hawaii. About halfway there, the ship begins to sink. You are able to board a lifeboat, but now you are floating in the ocean waiting to be rescued. After several days, you are so thirsty that you bend over the side of the boat and drink lots of salty seawater.
Explain what you think will happen to your body within a few hours of drinking the ocean water, and explain biological basis for your reaction.
9.
What is DNA fingerprinting and explain how this could be used in court or on a TV show such as CSI?
10.
DNA and RNA are similar yet distinct components of the cell. Describe three differences between RNA and DNA with respect to their chemical composition and structure. Provide a detailed description of each characteristic you chose
in your response.
11.
Why would you quickly die if not for the action of enzymes in your cells?
.
1.5 pages single spaced, include References and when necessary, imag.docxKiyokoSlagleis
This document provides guidelines for a 1.5 page single spaced summary assignment, noting that reputable scientific sources from databases and organizations like the CDC and WHO should be used to ensure scientific facts rather than opinions are presented. References and images with captions can be included as necessary, using primary literature if needed.
1.1- What are the real reasons behind the existence of Racism W.docxKiyokoSlagleis
1.
1- What are the real reasons behind the existence of Racism? Why does it still exist despite been illegal by law?
-
Each paragraph is explaining one reason. The reasons should be supported with examples and quotations from reliable sources.
-
List some forms of Racism, such as color, cultural, ethnic racism.
2.
2- Racism in developed countries, how do governments in these countries are standing against racism? Are there genuine efforts to end it forever? Is it real that there are some politicians who are behind this rejected act to get benefits?
3.
3- Human Rights, Civil Rights Movement and other organizations. What are they have done to help in this case?
4.
4- How is Racism existing in sports? Give some examples of that and how people reacted about them?
IMPORTANT NOTEs:
1- THE WRITING MUST BE AN INTERNATIONAL STUDENT LEVEL ( undergraduate Student )
2- please i need good word and something reasonable not too Academic,
No plagiarism
·
3-4 pages’ research.
·
At least you should use two reliable sources.
·
No plagiarism at all, I mean 0%.
·
The research should include: introduction which has clear thesis, paragraphs and conclusion.
·
Work cites.
·
Provide links for the sources if you can
.
1.) Connect 3 Due October 4th2.) Connect 4 Due Octob.docxKiyokoSlagleis
1.)
Connect 3
:
Due October 4th
2.)
Connect 4
:
Due October 16th
3.)
Research Paper: 8 Pages total
(Have Refernces already) APA Format,
Due October 16
4.)
Group Case Paper:
Due Oct 4
No exact lenght (see below points you must have in the paper APA Format).
What are the lessons that you think are important from the Madoff investment fraud as part of that overall meltdown?
-
Examine what could be done to prevent others from pulling off such a scam in the future
-
Present whether or not this fiasco has changed the mentality of potential investors
-
Was there any “Silver Lining” to what happened with the fraud?
.
1. Write an equation in standard form of the parabola that has th.docxKiyokoSlagleis
1.
Write an equation in standard form of the parabola that has the same shape as the graph of f(x) = 2x
2
, but with the given point as the vertex (5, 3).
A. f(x) = (2x - 4) + 4
B. f(x) = 2(2x + 8) + 3
C. f(x) = 2(x - 5)
2
+ 3
D. f(x) = 2(x + 3)
2
+ 3
2 of 20
5.0 Points
Find the coordinates of the vertex for the parabola defined by the given quadratic function.
f(x) = 2(x - 3)
2
+ 1
A. (3, 1)
B. (7, 2)
C. (6, 5)
D. (2, 1)
3 of 20
5.0 Points
Find the vertical asymptotes, if any, and the values of x corresponding to holes, if any, of the graph of the following rational function.
g(x) = x + 3/x(x + 4)
A. Vertical asymptotes: x = 4, x = 0; holes at 3x
B. Vertical asymptotes: x = -8, x = 0; holes at x + 4
C. Vertical asymptotes: x = -4, x = 0; no holes
D. Vertical asymptotes: x = 5, x = 0; holes at x - 3
4 of 20
5.0 Points
"Y varies directly as the n
th
power of x" can be modeled by the equation:
A. y = kx
n
.
B. y = kx/n.
C. y = kx
*n
.
D. y = kn
x
.
5 of 20
5.0 Points
40 times a number added to the negative square of that number can be expressed as:
A.
A(x) = x
2
+ 20x.
B. A(x) = -x + 30x.
C.
A(x) = -x
2
- 60x.
D.
A(x) = -x
2
+ 40x.
6 of 20
5.0 Points
The graph of f(x) = -x
3
__________ to the left and __________ to the right.
A. rises; falls
B. falls; falls
C. falls; rises
D. falls; falls
Solve the following formula for the specified variable:
V = 1/3 lwh for h
7 of 20
Write an equation that expresses each relationship. Then solve the equation for y.
x varies jointly as y and z
A. x = kz; y = x/k
B. x = kyz; y = x/kz
C. x = kzy; y = x/z
D. x = ky/z; y = x/zk
8 of 20
8 times a number subtracted from the squared of that number can be expressed as:
A. P(x) = x + 7x.
B.P(x) = x
2
- 8x.
C. P(x) = x - x.
P(x) = x
2
+ 10x.
9of 20
Find the x-intercepts. State whether the graph crosses the x-axis, or touches the x-axis and turns around, at each intercept.
f(x) = x
4
- 9x
2
A. x = 0, x = 3, x = -3; f(x) crosses the x-axis at -3 and 3; f(x) touches the x-axis at 0.
B. x = 1, x = 2, x = 3; f(x) crosses the x-axis at 2 and 3; f(x) crosses the x-axis at 0.
C. x = 0, x = -3, x = 5; f(x) touches the x-axis at -3 and 5; f(x) touches the x-axis at 0.
D. x = 1, x = 2, x = -4; f(x) crosses the x-axis at 2 and -4; f(x) touches the x-axis at 0.
10 of 20
Find the domain of the following rational function.
f(x) = x + 7/x
2
+ 49
A. All real numbers < 69
B. All real numbers > 210
C. All real numbers ≤ 77
D. All real numbers
11 of 20
Write an equation in standard form of the parabola that has the same shape as the graph of f(x) = 3x
2
or g(x) = -3x
2
, but with the given maximum or minimum.
Minimum = 0 at x = 11
A. f(x) = 6(x - 9)
B. f(x) = 3(x - 11)
2
C. f(x) = 4(x + 10)
D. f(x) = 3(x
2
- 15)
2
12 of 20
Solve the following polynomial inequality.
3x
2
+ 10x - 8 ≤ 0
A. [6, 1/3]
B. [-4, 2/3]
C. [-9, 4/5]
D. [8, 2/7]
13 of 20
Find the coordinate.
1.A health psychologist in a northern climate wants to evaluate .docxKiyokoSlagleis
1.
A health psychologist in a northern climate wants to evaluate the claim that UV lamps help lower depressive symptoms in middle-aged women. She recruits volunteers who meet the criteria for clinical depression and assigns them to two groups: one group receives a standard treatment for depression and undergoes a half hour of UV lamp therapy each day; the other group receives the same standard treatment for depression but without UV lamp therapy. At the end of two months, she administers a depression inventory where lower scores indicate fewer depressive symptoms (lower levels of depression). Assume all other variables are controlled for in the study. Evaluate the claim that depression treatment plus the UV lamp results in
lower
depression scores than depression treatment alone. (16 pts)
Depression Treatment + UV
Depression
Treatment Only
34
29
43
31
29
25
12
14
31
17
22
19
27
32
39
29
13
41
26
23
47
31
25
14
24
37
41
42
a)
SPSS output
b)
SPSS graph
c)
Current APA-style Results section
.
Temple of Asclepius in Thrace. Excavation resultsKrassimira Luka
The temple and the sanctuary around were dedicated to Asklepios Zmidrenus. This name has been known since 1875 when an inscription dedicated to him was discovered in Rome. The inscription is dated in 227 AD and was left by soldiers originating from the city of Philippopolis (modern Plovdiv).
A Free 200-Page eBook ~ Brain and Mind Exercise.pptxOH TEIK BIN
(A Free eBook comprising 3 Sets of Presentation of a selection of Puzzles, Brain Teasers and Thinking Problems to exercise both the mind and the Right and Left Brain. To help keep the mind and brain fit and healthy. Good for both the young and old alike.
Answers are given for all the puzzles and problems.)
With Metta,
Bro. Oh Teik Bin 🙏🤓🤔🥰
How to Manage Reception Report in Odoo 17Celine George
A business may deal with both sales and purchases occasionally. They buy things from vendors and then sell them to their customers. Such dealings can be confusing at times. Because multiple clients may inquire about the same product at the same time, after purchasing those products, customers must be assigned to them. Odoo has a tool called Reception Report that can be used to complete this assignment. By enabling this, a reception report comes automatically after confirming a receipt, from which we can assign products to orders.
THE SACRIFICE HOW PRO-PALESTINE PROTESTS STUDENTS ARE SACRIFICING TO CHANGE T...indexPub
The recent surge in pro-Palestine student activism has prompted significant responses from universities, ranging from negotiations and divestment commitments to increased transparency about investments in companies supporting the war on Gaza. This activism has led to the cessation of student encampments but also highlighted the substantial sacrifices made by students, including academic disruptions and personal risks. The primary drivers of these protests are poor university administration, lack of transparency, and inadequate communication between officials and students. This study examines the profound emotional, psychological, and professional impacts on students engaged in pro-Palestine protests, focusing on Generation Z's (Gen-Z) activism dynamics. This paper explores the significant sacrifices made by these students and even the professors supporting the pro-Palestine movement, with a focus on recent global movements. Through an in-depth analysis of printed and electronic media, the study examines the impacts of these sacrifices on the academic and personal lives of those involved. The paper highlights examples from various universities, demonstrating student activism's long-term and short-term effects, including disciplinary actions, social backlash, and career implications. The researchers also explore the broader implications of student sacrifices. The findings reveal that these sacrifices are driven by a profound commitment to justice and human rights, and are influenced by the increasing availability of information, peer interactions, and personal convictions. The study also discusses the broader implications of this activism, comparing it to historical precedents and assessing its potential to influence policy and public opinion. The emotional and psychological toll on student activists is significant, but their sense of purpose and community support mitigates some of these challenges. However, the researchers call for acknowledging the broader Impact of these sacrifices on the future global movement of FreePalestine.
Andreas Schleicher presents PISA 2022 Volume III - Creative Thinking - 18 Jun...EduSkills OECD
Andreas Schleicher, Director of Education and Skills at the OECD presents at the launch of PISA 2022 Volume III - Creative Minds, Creative Schools on 18 June 2024.
How to Setup Default Value for a Field in Odoo 17Celine George
In Odoo, we can set a default value for a field during the creation of a record for a model. We have many methods in odoo for setting a default value to the field.
🔥🔥🔥🔥🔥🔥🔥🔥🔥
إضغ بين إيديكم من أقوى الملازم التي صممتها
ملزمة تشريح الجهاز الهيكلي (نظري 3)
💀💀💀💀💀💀💀💀💀💀
تتميز هذهِ الملزمة بعِدة مُميزات :
1- مُترجمة ترجمة تُناسب جميع المستويات
2- تحتوي على 78 رسم توضيحي لكل كلمة موجودة بالملزمة (لكل كلمة !!!!)
#فهم_ماكو_درخ
3- دقة الكتابة والصور عالية جداً جداً جداً
4- هُنالك بعض المعلومات تم توضيحها بشكل تفصيلي جداً (تُعتبر لدى الطالب أو الطالبة بإنها معلومات مُبهمة ومع ذلك تم توضيح هذهِ المعلومات المُبهمة بشكل تفصيلي جداً
5- الملزمة تشرح نفسها ب نفسها بس تكلك تعال اقراني
6- تحتوي الملزمة في اول سلايد على خارطة تتضمن جميع تفرُعات معلومات الجهاز الهيكلي المذكورة في هذهِ الملزمة
واخيراً هذهِ الملزمة حلالٌ عليكم وإتمنى منكم إن تدعولي بالخير والصحة والعافية فقط
كل التوفيق زملائي وزميلاتي ، زميلكم محمد الذهبي 💊💊
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2. trauma. However, it is important to recognize when bleeding
problems are more serious or
more frequent due to an underlying hemostatic abnormality.
Abnormal bleeding represents an important health care problem.
For example, in the
United States, it has been estimated that at least 5% to 10% of
women of childbearing age
seek medical care for menorrhagia and have bleeding severe
enough to require medical
intervention. Among the many defects that can cause abnormal
bleeding, inherited and
acquired von Willebrand disease (VWD) and platelet function
disorders are much more
common than defects in coagulation and fibrinolytic proteins.
PATHOPHYSIOLOGY
REVIEW OF NORMAL HEMOSTASIS
Hemostasis consists of the following steps: (1) initiation and
formation of the platelet
plug, also known as primary hemostasis; (2) propagation and
amplification of the clotting
“cascade” or secondary hemostasis, which involves activation of
a series of coagulation
factors resulting in the generation of thrombin that cleaves
fibrinogen to fibrin; (3) cross-
linking of fibrin; (4) termination of procoagulant response by
antithrombotic control
mechanisms; (5) removal of the clot by fibrinolysis; and (6)
tissue repair and regeneration.
When a vessel is injured, platelets adhere to exposed collagen
and other components
of the subendothelium as the first defense against bleeding. This
3. initial adhesion is
dependent on von Willebrand factor (VWF) as well as specific
platelet receptors (eg,
glycoprotein IbIXV) for VWF and collagen. This adhesion leads
to platelet activation and
shape change as well as platelet aggregation, which promotes
recruitment of additional
platelets.
Coagulation is initiated in vivo when endothelial or vascular
cells are damaged. This
results in exposure of blood to tissue factor (TF), which binds
to factor VII (FVII) and its
activated form, factor VII (FVIIa). TF-FVIIa complexes
(extrinsic tenase) then activates
factors IX and X directly. Activated factor IX can also form a
complex with factor VIIIa as
well as phospholipids and calcium, called the intrinsic tenase
complex, which promotes
further conversion of factor X to factor Xa. The generated
factor Xa associates with
activated factor V, phospholipids, and calcium to form the
prothrombinase complex that
activates prothrombin to thrombin. Intrinsic and extrinsic tenase
are needed to generate
enough thrombin for normal hemostasis. Once thrombin is
generated, it cleaves fibrinogen
to fibrin, which leads to formation of a fibrin clot and promotes
platelet activation and the
generation of activated factors V and VIII. Thrombin also
results in the formation of
activated XIII, an enzyme that cross-links fibrin to make the
clot more resistant to
fibrinolysis (the cleavage of the fibrin clot).
When coagulation is activated, fibrinolysis is activated, leading
5. formation, due to the
associated factor VIII deficiency. Drugs that inhibit platelet
function (eg, aspirin,
nonsteroidal anti-inflammatory drugs, serotonin reuptake
inhibitors) and those that inhibit
coagulation (eg, heparin, warfarin) are important causes to
consider when evaluating and
managing an individual with bleeding.
TABLE 172-1 Questions to Consider when Evaluating a Patient
for a Possible Bleeding
Disorder
What are the patient’s bleeding symptoms?
• Is there a personal or family history of bleeding with trauma
or procedures?
• What are the site(s) of bleeding?
• For women: Is there a history of prolonged, heavy periods or
bleeding with childbirth?
• What is the severity of bleeding?
• What is the duration of bleeding events?
• Has the patient required any treatments for bleeding?
Does the history suggest a congenital or acquired problem?
• Note: For congenital bleeding disorders, the bleeding
symptoms may date back to
childhood and may affect other family members; acquired
bleeding disorders should be
considered when the bleeding problems are more recent, and a
drug-induced defect
should be excluded.
What is the timing of the bleeding?
• Is the bleeding immediate or delayed (onset one or more days
after challenges)?
Is the bleeding systemic or local?
7. WHEN TO SUSPECT A BLEEDING DISORDER
In general, a bleeding disorder should be suspected when
bleeding occurs with minimal or
no provocation, when it is more severe than expected for a
given challenge, and when
bleeding episodes occur repeatedly with challenges. Care should
be taken to avoid asking
very subjective questions about bleeding. For example, it is
preferable to ask women about
menstrual periods lasting longer than 7 days, with more than 2
to 3 days of heavy flow,
and/or periods that interfere with their lifestyle than to ask if
they experience “heavy”
periods. Similarly, asking about bruises as big as or larger than
oranges and/or bruises
appearing without provocation is better than asking about “easy
bruising.”
While individuals with severe bleeding problems may report
spontaneous bleeding and
serious bleeding with major and minor hemostatic challenges,
individuals with milder
defects can report abnormal bleeding with some but not all
significant hemostatic
challenges. While inherited, severe bleeding problems typically
present early in life, milder
inherited bleeding problems and acquired bleeding problems
often get diagnosed in adult
life. The clinical assessment should be directed toward
identifying the type and severity of
bleeding problems experienced by an individual, in order to
plan appropriate laboratory
testing and therapy.
KEY COMPONENTS OF THE HISTORY
8. What are the patient’s bleeding symptoms?
The patient should be questioned about his or her current
bleeding symptoms and past
bleeding symptoms and a family history of bleeding problems
(Table 172-2). The
following characteristics of the bleeding should be determined:
association with trauma or
procedures and if it occurred with some or all minor and major
procedures; site(s)
(including joint bleeds); severity (eg, bleeding resulting in
additional interventions such as
blood transfusions, intensive care unit admission, and/or
prolongation of hospitalization
stay); duration of bleeding; and any treatments that were given
to control bleeding (types
of drugs or blood products). It may be helpful to determine if
the patient received
anticoagulants or drugs that inhibit platelet function. Female
patients should be asked
questions about menstrual periods and abnormal bleeding with
childbirth and pregnancy
losses. Mucocutaneous bleeding (ie, abnormal bruising, gum
bleeding, and epistaxis) is
more suggestive of a defect in primary hemostasis. Some
bleeding symptoms, such as
deep tissue bleeding, joint hemorrhages, and spontaneous
unexplained hematuria are
uncommon but can occur in severe inherited coagulation protein
deficiencies. Some
bleeding problems, such as epistaxis, can be experienced by
individuals without bleeding
disorders. Bleeding after trauma should be considered but can
be difficult to evaluate
because it is not specific to individuals with bleeding disorders.
11. The bleeding history is often used to assess when abnormal
bleeding occurred (eg, same
day or days later) relative to invasive surgical or dental
procedures. Bleeding during,
immediately after, or on the same day as the challenge is
suggestive of a disorder of
primary hemostasis (see Disorders of Primary Hemostasis later
in this chapter), whereas
bleeding that becomes problematic one or more days after a
challenge is more typical of a
factor deficiency or a fibrinolytic defect.
Is the bleeding disorder congenital or acquired, and are there
aggravating or
contributing factors?
Inherited problems tend to present earlier in life than acquired
problems unless they are
mild. Inherited problems are often associated with a positive
family history, which may be
negative if the condition is recessive or X-linked. A thorough
bleeding history should
include questions about potential aggravating or contributing
factors such as new
medications (eg, aspirin or antidepressant therapy).
Individuals with acquired bleeding disorders often describe
bleeding that is more recent
in onset. Causes of an acquired bleeding disorder are listed in
Table 172-2 and include
liver disease, vitamin K deficiency, autoimmune-mediated
conditions (eg, immune
thrombocytopenic purpura), hypothyroidism, acquired factor
VIII deficiency or acquired
VWD, and other conditions such as Cushing syndrome.
12. It is important to emphasize that the patient’s entire bleeding
history must be assessed
in order to determine if the problem is mild or severe and if it is
likely congenital or
acquired.
Has the patient experienced any hemostatic challenges?
Patients should be questioned about how many operative and
invasive dental procedures
they have undergone, and how many of these were associated
with abnormal bleeding. It
may be helpful to ask if the patient has experienced any
unusually large ecchymosis
around incisions when evaluating the surgical bleeding history.
It is important to note that
individuals who have undergone a number of common surgical
and dental procedures (eg,
tonsillectomy, wisdom tooth extraction) without experiencing
abnormal bleeding might
still have a mild bleeding problem (particularly if other aspects
of their bleeding history are
abnormal); however, they are unlikely to have a severe bleeding
disorder. Alternately, it is
important to recognize that sometimes abnormal bleeding occurs
in healthy individuals
undergoing a major procedure due to technical complications.
What is the patient’s general medical history? Is there a
systemic disease that is causing
or contributing to the patient’s bleeding symptoms?
An evaluation of a patient’s general medical history for new or
worsening bleeding, and
other changes in health, is important for assessing undiagnosed
liver, kidney, or endocrine
14. clopidogrel, serotonin reuptake
inhibitors, or fish oil supplements); or defective coagulation
(eg, due to heparin or
warfarin).
PHYSICAL EXAMINATION
The physical examination is often not very informative in
individuals with a bleeding
disorder. An initial assessment of acute bleeding should
determine the patient’s
hemodynamic status and if there are signs of anemia. Blood
blisters in the mouth,
hemorrhages on the bite margins in the mouth, and petechiae
(tiny red-colored skin lesions
that reflect small hemorrhages into the skin, particularly on
dependent parts of the body
and at sites of trauma) may suggest significant
thrombocytopenia. Large bruises or
purpura may suggest a defect in primary hemostasis or acquired
hemophilia. Sometimes
the purpuric skin lesions of severe anticoagulant protein
deficiencies (eg, purpura
fulminans due to severe congenital protein C deficiency) are
mistaken for skin bleeding.
Abnormalities in joints, lymph nodes, spleen, and liver should
raise concern for the
possibility of a secondary bleeding disorder.
DIFFERENTIAL DIAGNOSIS BASED ON CLINICAL
ASSESSMENT
Table 172-3 outlines the differences between disorders of
primary and secondary
hemostasis.
16. Menorrhagia Common May occur
Inheritance (if congenital) Dominant or recessive Most common
cause
(hemophilia) is X-linked
Disorders of primary hemostasis
Patients with disorders of primary hemostasis will often
describe experiencing abnormal
bleeding during or within a few hours of a surgical or dental
procedure. These problems,
with or without mucocutaneous bleeding symptoms, should raise
questions about VWF
and platelet abnormalities (both qualitative and quantitative) or,
less commonly, blood
vessel abnormalities. Defects in primary hemostasis can also
present as troublesome
epistaxis and/or gingival bleeding, petechiae, superficial
bruising or ecchymosis, and
menorrhagia. Petechiae are very suggestive of a platelet or
vascular disorder.
Disorders of secondary hemostasis
Disorders of secondary hemostasis typically manifest as
delayed-onset bleeding that
becomes evident in the days following trauma or surgical
procedure. When there is a
severe factor deficiency, there can be spontaneous bleeding into
joint spaces
(hemarthroses) and into deep, soft tissues (eg, muscle
hematomas). The most common
inherited disorders of secondary hemostasis include hemophilia
A (factor VIII deficiency)
17. and hemophilia B (factor IX deficiency). Acquired hemophilia,
due to an antibody directed
against factor VIII, accounts for about 10% of all hemophilia.
Factor XIII deficiency and
fibrinolytic disorders can also present with delayed bleeding,
but these conditions are less
common. Acquired autoantibodies against coagulation proteins
are important but
infrequent causes of bleeding and most commonly affect factor
VIII, VWF, factor XIII or
factor V.
HOW SHOULD THIS PATIENT WITH A SUSPECTED
BLEEDING DISORDER BE
INVESTIGATED?
Investigations for bleeding problems need to consider the
etiologies of mild and severe
and common and rare disorders. Figure 172-1 summarizes a
stepwise approach to
investigation, some of which may be performed at the time of a
specialist evaluation.
Often, a broad range of tests is needed to assess an individual
with a suspected bleeding
disorder (see Figure 172-1). A complete blood count is helpful
to evaluate for
thrombocytopenia and to determine if there are other
hematologic abnormalities such as
anemia (which may reflect acute or chronic bleeding), or white
blood cell abnormalities
that may suggest an underlying bone marrow disorder. An
assessment for iron deficiency
(which may be present without anemia) should be considered. A
blood group and
antibody screen should be done before surgery in individuals
with a history of abnormal
19. coagulation tests.
TABLE 172-4 Differential Diagnosis of Coagulation Test
Abnormalities
PT APTT
Thrombin
Time Fibrinogen Platelet Count
Reference Intervals
~ 10-
13 s
Ranges
Vary
Ranges
Vary
150-400 mg/dL
1.5-4.0 g/L
150-400 ×
106/mL
Fibrinogen deficiency N – ↑ N – ↑ ↑ ↓ N
Factor VII deficiency ↑ N N N N
Factor VIII, IX, or XI
deficiency
N ↑ N N N
Factor II, V, X deficiency ↑ ↑ N N N
20. Factor deficiencies not
associated with bleeding
(factor XII, high-
molecular-weight
kininogen or prekallikrein
deficiency)
N ↑ N N N
Acquired hemophilia and
congenital hemophilia
with inhibitors
N ↑* N N N
Lupus anticoagulant N – ↑ N – ↑† N – ↑ N N
Heparin therapy or
sample contamination
N – ↑ ↑ ↑↑ N N
Liver disease N – ↑ N – ↑ N – ↑ ↓ – N – ↑ ↓ – N
Vitamin K deficiency ↑ N – ↑ N N N
Fibrinolytic therapy ↑ ↑ ↑ ↓ N
Consumptive
coagulopathy
N – ↑ ↑ ↑ ↓ ↓
Dilutional coagulopathy N – ↑ N – ↑ N – ↑ ↓ – N ↓
von Willebrand disease N N – ↑ N N N ↓ in type 2B
22. Additional tests can be helpful to evaluate if there is a history
of acquired bleeding,
which could reflect liver or renal disease or an endocrine
disorder such as hypothyroidism
or Cushing syndrome. As fibrinolytic defects are uncommon,
testing is rarely done except
by specialists.
PRACTICE POINT
In general, the patient’s symptoms, not the laboratory values,
should be treated. Local
factors can be significant contributors to bleeding and should be
considered in the
plans for investigation and treatment, even in patients with
documented
coagulopathies. Always consider risks and benefits (including
those of treating or not
treating) when deciding on appropriate therapies as the risks of
certain therapies
include increased prothrombotic risks. Patients with congenital
bleeding disorders are
best managed in a multidisciplinary care setting to plan
treatment and prevention of
acute bleeding episodes and to deal with complications (eg,
hemophilic arthropathy).
Information on the patient’s bleeding problem and the treatment
plans must be
communicated to both the patient and their health care
providers.
HOW SHOULD THIS PATIENT WITH A BLEEDING
DISORDER BE TREATED?
The management of each patient with a bleeding disorder
24. anticoagulants, anti-
inflammatory drugs that inhibit platelet function) should be
modified because of the
patient’s bleeding problems.
Information on the patient’s bleeding problem and the treatment
plans must be
communicated to both the patient and his health care providers.
Patients with
congenital bleeding disorders must be “taught” that prophylactic
treatment is required
prior to invasive procedures.
Patients with congenital bleeding disorders are best managed in
a multidisciplinary
care setting to plan treatment and prevention of acute bleeding
episodes and to deal
with complications (eg, hemophilic arthropathy).
OTHER ISSUES TO CONSIDER FOR TREATMENT OF
CONGENITAL BLEEDING
DISORDERS
Treatments for factor deficiencies
Individuals with moderate-to-severe clinically significant factor
deficiencies often require
factor concentrates (recombinant products generally preferred
over plasma-derived
products), although some conditions and circumstances (eg,
mild hemophilia due to
factor VIII deficiency with mild bleeding) may be managed with
desmopressin. Fibrinolytic
inhibitor drugs (aminocaproic acid and tranexamic acid) are
often used as an adjunctive
therapy for some procedures, such as dental and oral-nasal
surgeries. Fibrinolytic inhibitor
drugs are the treatment of choice for fibrinolytic disorders.
26. GENERAL MANAGEMENT OF COMMON ACQUIRED
BLEEDING DISORDERS
Liver disease
The coagulopathy related to liver disease is multifactorial, as
the liver is the major source
of all hemostatic proteins in plasma except for VWF and tissue
plasminogen activator.
Individuals with liver disease often have deficiencies of
multiple coagulation factors, and
in mild liver disease, there can be low levels of factors VII and,
at times, factors XI and XII.
Fibrinogen deficiency is typically only seen with severe liver
disease. In fact, fibrinogen
levels are often elevated in mild liver disease. Sometimes
patients with liver disease have
additional hemostatic defects such as vitamin K deficiency,
thrombocytopenia,
dysfibrinogenemia, platelet function abnormalities, and
disseminated intravascular
coagulation (DIC). If an individual with coagulopathy from
liver disease requires treatment
(ie, for active bleeding or, in some instances, before a procedure
associated with a
significantly increased risk of bleeding), one or more of the
following treatment options
should be considered: vitamin K replacement (if deficient),
plasma infusion (typically
requires four or more units to have measurable effects),
fibrinogen replacement (with
cryoprecipitate or fibrinogen concentrate), and/or platelet
transfusion. The role of
prothrombin complex concentrates in patients with liver disease
is uncertain.
27. Anticoagulant medications
Treatment of serious bleeding due to anticoagulants may require
reversal of the
anticoagulant. Patients on an oral vitamin K antagonist, who
require reversal to treat
bleeding, should receive vitamin K, and when more rapid
reversal is required (eg, to treat
life-threatening gastrointestinal bleeding), prothrombin complex
concentrate (if available)
or plasma infusion should be considered. Protamine sulfate can
be considered when there
is a need to rapidly reverse unfractionated heparin or low -
molecular-weight heparin
because of bleeding. However, this treatment reverses only
about 60% of the antifactor Xa
activity of low-molecular-weight heparin. Unfortunately, agents
are not currently available
to rapidly reverse some of the newer, novel anticoagulants that
are direct inhibitors of
thrombin or factor Xa. However, specific antidotes for direct
thrombin inhibitors and factor
Xa inhibitors have been developed and are undergoing clinical
testing. It is unclear
whether bleeding from these newer agents is improved by
treatment with desmopressin
acetate, fibrinolytic inhibitor drugs, or other treatments, such as
prothrombin complex
concentrates and factor VIIa.
Vitamin K deficiency
Acquired bleeding due to vitamin K deficiency results from
decreased gamma-
carboxylation of the vitamin K-dependent factors II, VII, IX,
and X and can be treated by
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