Venous thromboembolism (VTE) manifests as deep vein thrombosis (DVT) or pulmonary embolism (PE) from thrombus formation in the venous circulation. Risk factors include immobilization, surgery, trauma, cancer, and genetic hypercoagulable states. Symptoms are nonspecific so objective tests like ultrasound or CT scan are needed to diagnose. Prevention involves pharmacologic methods like blood thinners or compression stockings, and non-pharmacologic methods like early ambulation. Treatment consists of acute blood thinners followed by long-term oral anticoagulants to prevent recurrence, with duration depending on provoking factors.
Deep vein thrombosis (DVT) and Pulmonary embolism (PE)Aminul Haque
Deep vein thrombosis (DVT) and pulmonary embolism (PE), collectively referred to as venous thromboembolism (VTE), constitute a major global burden of disease.
Deep vein thrombosis (DVT) and Pulmonary embolism (PE)Aminul Haque
Deep vein thrombosis (DVT) and pulmonary embolism (PE), collectively referred to as venous thromboembolism (VTE), constitute a major global burden of disease.
Is routine thromboprophylaxis warranted in all patients of tibial fracture ma...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Is routine thromboprophylaxis warranted in all patients of tibial fracture ma...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
2. Venous thromboembolism (VTE) is one of the most common
cardiovascular disorders in the United States.
VTE is manifested as deep vein thrombosis (DVT) and pulmonary
embolism (PE) resulting from thrombus formation in the venous
circulation.
It is often provoked by prolonged immobility and vascular
injury and most frequently seen in patients hospitalized for a
serious medical illness, trauma, or major surgery.
VTE can also occur with little or no provocation in patients who
have an underlying hypercoagulable disorder.
3. The risk of VTE is related to several factors
including age, history of VTE, major surgery
(particularly orthopedic procedures of the lower
extremities), trauma, malignancy, pregnancy,
estrogen use, and hypercoagulable states.
Estrogen-containing contraceptives, estrogen
replacement therapy, and many of the selective
estrogen receptor modulators (SERMs) increase the
risk of venous thrombosis.
4. The symptoms of DVT or PE are nonspecific, and it is
extremely difficult to distinguish VTE from other
disorders on clinical signs alone.
Therefore, objective tests are required to confirm or exclude
the diagnosis.
Patients with DVT frequently present with unilateral leg
pain, swelling that can persist after a night’s sleep, and
cyanosis of the skin in the affected leg
5. Signs, symptoms and risk factors can be used to categorize the
patient as at low, intermediate, or high probability of having acute
DVT.
This model, known as the Wells Criteria, is summarized in Table.
If the clinical probability of DVT is low, the D-dimer test can be
used to confirm the patient does not have DVT.
The D-dimer test is a quantitative measure of fibrin breakdown in
the serum, and it is a marker of acute thrombotic activity.
D-dimer assays are sensitive but not specific markers for VTE,
so a negative D-dimer test can be used to rule out the diagnosis
of DVT.
6. If the D-dimer test is positive in a low
probability patient, or if the patient has a
moderate or high probability of DVT.
7. Duplex ultrasonography is the most commonly used test to
diagnose DVT.
It is a noninvasive test that can measure the rate and direction
of blood flow and visualize clot formation in veins of the
legs.
Venography (also known as phlebography) is the gold standard
for the diagnosis of DVT.
However, it is an invasive test that involves injection of
radiopaque contrast dye into a foot vein.
o It is expensive and can cause anaphylaxis and
nephrotoxicity.
8. Laboratory Tests
The initial laboratory evaluation should include complete
blood count (CBC) with differential, coagulation studies (such
as prothrombin time [PT]/international normalized ratio [INR],
activated partial thromboplastin time [aPTT]), serum
chemistries with renal and liver function.
Serum concentrations of D-dimer, a by-product of thrombin
generation, will be elevated in an acute event.
A negative D-dimer in a patient with low clinical
probability of DVT can be used to rule out DVT.
9. Clinical Probability
Apply the Wells criteria to determine the
probability that the patient’s signs, symptoms,
and risk factors are the result of DVT (Table)
10.
11.
12. PREVENTION
• Given that VTE is often clinically silent and potentially fatal,
prevention strategies have the greatest potential to improve patient
outcomes.
The goal of an effective VTE prophylaxis program is to identify
all patients at risk, determine each patient’s level of risk, and select
and implement regimens that provide sufficient protection for the
level of risk.
• At the time of hospital admission, change in level of care, and prior to
discharge, all patients should be evaluated for risk of VTE, and
appropriate prophylaxis strategies should be routinely used.
• Prophylaxis should be continued throughout the period of risk.
13.
14.
15. Several pharmacologic and non-pharmacologic
methods are effective for preventing VTE, and these
can be used alone or in combination.
Non-pharmacologic methods improve venous blood
flow by mechanical means
drug therapy prevents thrombus formation by
inhibiting the coagulation cascade.
16. Non-pharmacologic Therapy
Ambulation as soon as possible following surgery lowers the incidence of
VTE in low-risk patients.
Walking increases venous blood flow and promotes the flow of natural
antithrombotic factors into the lower extremities. All hospitalized patients
should be encouraged to ambulate as early as possible, and as frequently as
possible.
Graduated compression stockings (GCS) are specialized hosiery that
provide graduated pressure on the lower legs and feet to help prevent
thrombosis.
Compared with anticoagulant drugs, GCS are relatively inexpensive
and safe; however, they are less effective and not recommended in
moderate to higher risk patients
17. They offer an alternate choice in low- to moderate-risk
patients when pharmacologic interventions are
contraindicated.
When combined with pharmacologic interventions,
GCS have an additive effect.
However, some patients are unable to wear
compression stockings because of the size or shape
of their legs, and some patients may find them hot,
confining, and uncomfortable.
18. Pharmacologic Therapy
Appropriately selected drug therapies can dramatically reduce
the incidence of VTE in medical and surgical patients.
The choice of medication and dose to use for VTE prevention
must be based on:
The patient’s level of risk for thrombosis
Bleeding risk
The cost
Availability of an adequate drug therapy monitoring system.
19. The most extensively studied drugs for the prevention of VTE
are unfractionated heparin (UFH), the low molecular weight
heparins (LMWHs; dalteparin and enoxaparin), fondaparinux, and
warfarin.
Generally the LMWHs provide improved protection
against VTE when compared with low-dose UFH in most
medical and surgical patients and when compared to low-dose
UFH and warfarin in major orthopedic surgery patients.
Fondaparinux is more effective than LMWH in patients
undergoing high-risk orthopedic surgery, but it has a
heightened risk of bleeding.
20. For hospitalized general surgical and medical
patients, the available evidence supports the
use of
UFH (5000 Units every 12 or 8 hours),
enoxaparin 40 mg subcutaneously (SC) daily,
dalteparin 2500 to 5000 Units SC daily,
or fondaparinux 2.5 mg SC daily.
21. For the prevention of VTE following major orthopedic
surgery, current evidence supports the use of UFH,
LMWH, fondaparinux, adjusted dose warfarin, aspirin,
and the newer direct oral anticoagulants (DOACs):
apixaban, dabigatran and rivaroxaban.
Additionally, the role of aspirin for VTE prevention
is controversial as it produces a very modest
reduction in VTE following orthopedic surgeries of
the lower extremities
22. The effectiveness of UFH, aspirin, and warfarin is lower than
LMWH, thus current American College of Chest Physicians
(ACCP) guidelines recommend the use of LMWH or
fondaparinux preferentially over other pharmacologic options in
major orthopedic surgery patients.
The appropriate prophylactic dose for each LMWH product in
orthopedic surgery is indication specific;
enoxaparin 30 mg SC twice daily, enoxaparin 40 mg SC
daily, and dalteparin 5000 Units SC daily are the most
commonly used regimens.
The dose of fondaparinux is 2.5 mg SC daily.
23. The dose of warfarin, another commonly used option for
prevention of VTE following orthopedic surgery, must be
adjusted to maintain an INR between 2 and 3.
Oral administration and low drug acquisition cost give warfarin
some advantages over the LMWHs and fondaparinux.
However, warfarin does not achieve its full antithrombotic
effect for several days and requires frequent monitoring and
periodic dosage adjustments, making therapy cumbersome.
Warfarin should only be used when a systematic patient
monitoring system is available.
24. The oral factor Xa inhibitors rivaroxaban and apixaban are newer
options for VTE prevention following hip and knee replacement
surgery and offer a convenient alternative to traditional
anticoagulants.
Both agents have shown superior efficacy compared to LMWH with
a similar rate of bleeding complications.
Rivaroxaban is given at a fixed dose of 10 mg once daily, and
apixaban is given at a fixed dose of 2.5 mg twice daily. Both are
given without the need for routine laboratory monitoring and dosing
adjustments (as with warfarin) and without the inconvenience of
administration by injection (as with LMWH and fondaparinux).
25. The optimal duration for VTE prophylaxis is not well
established but should be given throughout the period of
risk.
For patients who have undergone total knee replacement,
total hip replacement, or hip fracture repair, prophylaxis is
recommended for a minimum of 10 to 14 days
however, extending it up to 35 days is recommended due
to continued VTE risk up to one month postsurgery.
26. General Treatment Principles
Anticoagulant drugs are considered the mainstay of therapy for
patients with VTE, and the therapeutic strategies for DVT and PE are
similar.
Management decisions are guided by balancing the risks and benefits
of various treatment options.
The treatment of VTE can be divided into three phases: acute (first
5–10 days), long term (first 3 months), and extended (beyond 3
months).
The acute treatment phase of VTE is typically accomplished by
administering a fast-acting parenteral or a DOAC
27. Accomplished using oral anticoagulant agents such as warfarin,
or one of the DOACs (apixaban, dabigatran, and rivaroxaban).
In certain populations, such as patients with cancer and women who
are pregnant, the LMWHs are the preferred agents during long-term
and extended treatment phases due to better safety or efficacy.
The etiology of VTE will guide the duration of therapy. VTE can be
provoked (by transient risk factors), unprovoked (or idiopathic) and
cancer associated.
Patients with unprovoked or cancer associated VTE have a
significantly higher risk of recurrence compared to patients
with provoked VTE.
28.
29. In the absence of contraindications, the treatment of VTE should
initially include a rapid-acting injectable anticoagulant (eg, UFH,
LMWH, fondaparinux) or a rapidly acting DOAC (eg, apixaban,
rivaroxaban).
If warfarin is used for oral anticoagulation, it should be initiated
on the same day as the parenteral anticoagulant, and the
parenteral agent should be overlapped for a minimum of 5 days
and until the INR is greater than or equal to 2 for at least 24
hours.
30. Due to significant variability in interpatient response and changes in
patient response over time, UFH requires close monitoring and
periodic dose adjustment.
The response to UFH can be monitored using a variety of
laboratory tests including the aPTT, the whole blood clotting
time, activated clotting time (ACT) and the plasma heparin
concentration.
o Although it has several limitations, the aPTT is the
most widely used test in clinical practice to monitor
UFH.
31. Side effects associated with UFH include
o bleeding,
o thrombocytopenia,
o hypersensitivity reactions, and, with prolonged use,
o alopecia,
o hyperkalemia,
o and osteoporosis.
Bleeding is the most common adverse effect associated with
antithrombotic drugs including UFH therapy UFH is FDA
pregnancy category C and may be used to treat VTE during
pregnancy.
32. UFH should be stopped immediately and the source of bleeding
treated.
If necessary, use protamine sulfate to reverse the effects of UFH.
The usual dose is 1 mg protamine sulfate per 100 units of UFH, up to
a maximum of 50 mg, given as a slow IV infusion over 10 minutes.
The effects of UFH are neutralized in 5 minutes, and the effects of
protamine persist for 2 hours.
If bleeding is not controlled or the anticoagulant effect rebounds,
repeated doses of protamine may be administered
33. Heparin-induced thrombocytopenia (HIT) is a very serious adverse
effect associated with UFH use.
Platelet counts should be monitored every 2 to 3 days during the
course of UFH therapy.
HIT should be suspected if the platelet count drops by more than 50%
from baseline or to below 150 × 103/mm3 (150 × 109/L).
HIT should also be suspected if thrombosis occurs despite UFH use.
Immediate discontinuation of all heparin-containing products including
the use of LMWHs is in order.
Alternative anticoagulation with direct thrombin inhibitors (DTIs)
should be initiated.
34. Routine monitoring of LMWHs activity and dose adjustments are not
required in most patients.
LMWHs have longer plasma half-lives, allowing once- or twice-
daily administration, improved SC bioavailability, and dose-
independent renal clearance.
They are also associated with a lower incidence of HIT and osteopenia.
Two LMWHs are currently available in the United States: dalteparin
and enoxaparin.
The dose of LMWHs for the treatment of VTE is determined based on
the patient’s weight and is administered SC once or twice daily.
35. Direct thrombin inhibitors (DTIs) are considered the drugs of choice for
the treatment of VTE in patients with a diagnosis or history of HIT.
Several injectable DTIs are approved for use in the US including
lepirudin, bivalirudin, argatroban, and desirudin
In patients with acute VTE, a rapid-acting anticoagulant (UFH, LMWH,
or fondaparinux) should be overlapped with warfarin for a minimum of
5 days and until the INR is greater than 2 and stable.
This is important because the full antithrombotic effect will not be
reached until 5 to 7 days or even longer after initiating warfarin
therapy.
36. Adjustments in the maintenance warfarin dose should be
determined based on the total weekly dose and by reducing or
increasing the weekly dose by increments of 5% to 25%.
When adjusting the maintenance dose, wait at least 7 days to
ensure a steady state has been attained on the new dose before
checking the INR again.
Checking the INR too soon can lead to inappropriate dose
adjustments and unstable anticoagulation status
37. The World Health Organization (WHO) recommended the INR to
monitor warfarin therapy.
For treatment and prevention of VTE, the INR target is 2.5
with an acceptable range of 2 to 3.
Before initiating warfarin therapy, a baseline PT/INR and CBC should
be obtained.
After initiating warfarin therapy the INR should be monitored at least
every 2 to 3 days during the first week of therapy.
Once a stable response to therapy is achieved, INR monitoring is
performed less frequently, weekly for the first 1 to 2 weeks, then every 2
weeks, and every 4 to 6 weeks thereafter if the warfarin dose and the
patient’s health status are stable.
Editor's Notes
The use of estrogen-containing contraceptives is associated with a two- to six-fold increased risk of venous thromboembolism (VTE). However, whether an estrogen-containing contraceptive-related VTE can be classified as 'unprovoked' or 'provoked' remains controversial
Venography (also called phlebography or ascending phlebography) is a procedure in which an x-ray of the veins, a venogram, is taken after a special dye is injected into the bone marrow or veins.
Duplex ultrasound involves using high frequency sound waves to look at the speed of blood flow, and structure of the leg veins. The term "duplex" refers to the fact that two modes of ultrasound are used, Doppler and B-mode.